LUMINA Podcasts

To provide value-based care, providers need to address their process, their technology, and their people. But stakeholder priorities don’t always align. Knowing where and how to start can be the difference between a successful implementation and one that falls short.  

Tune into the latest episode of Value-Based Care Insights featuring host Daniel J. Marino as he welcomes Sarah Hartley and Dr. Purvi Shah, whose expertise in ambulatory clinical documentation improvement (CDI) will help illustrate the need to improve clinical workflows.  In addition, they discuss the risks, challenges and obstacles providers need to navigate in order to better deliver meaningful patient outcomes. 

KEY TAKEAWAYS: 

• Coding and clinical guidelines don’t always align with documentation guidelines 
• To start a CDI program, peer-to-peer education is a critical key to success 
• Providers need to advance clinical workflow and documentation in order to meet the needs of patient populations 

LISTEN TO THE EPISODE:

 

 Transcript:

Daniel J. Marino: 

Welcome to value-based care insights. I'm your host, Daniel Marino. As we have talked about on the program many, many times. There is such a transition that has to occur as we enter into value-based contracts. And in particularly as we enter into risk-based contracts.  

You know, as we all know, value base really allows us to manage the population. We are focused on many different outcomes, many different changes that support our physicians, and whether it be their clinical workflow or changes in the care model. All of that becomes important, especially if we want to take care of patients beyond just the care that is being done within their clinics. The documentation, the care model, the support that we give to our patients, critically important, that drives the success of our value-based contracts.  

But when we think about that, there has been so much attention that it's been given to changes in the care model and the level of outcomes that we need to focus on. Only now are we starting to see the importance of modifications of enhancements to our clinical documentation. So in today's episode, we are going to spend some time talking about the new initiative. And it is not really new, because it has been happening for quite a while, particularly on the hospital side. But the need to really advance the ambulatory clinical documentation improvement. I am excited about today's discussion. 

We've got 2 ladies joining us that have done a great job within their health systems within their programs on building a real strong clinical documentation improvement program on the ambulatory side. First joining us today is Dr. Purvi Shah. 

 Dr. Shah is a primary care intern as a medical director of population health for a large health system here in Chicago, also joined by her colleague, the administrator System director, ambulatory risk adjustment and clinical documentation in Tyler, gritty, Sarah Hartley. 

Sarah and Dr. Shah. Welcome to the program. 

Sarah Hartley:

Thank you. Glad to be here.

Daniel J. Marino:

So Sarah, let us start with you. You know, as I mentioned, and we have done quite a bit of work helping organizations move into value-based care everything from strategies to the managed care contracting, lot of folks have focused on their clinical programs, looking at the outcomes, maybe enhancing some of their systems. Let us focus on the documentation. 

Why, all of a sudden, in your opinion, has this been a focus? Why has it not been a focus sooner as organization started to get involved in value-based care.

Sarah Hartley:

Sovalue-based care has been around for a while. But it has been focused on the hospital side, right? And so as we see the industry shift and wanting to treat our patients on the outpatient basis, keeping them out of the hospital, keeping our costs lower. We are shifting that model to our ambulatory settingand the goal is to keep the patients out of the hospital, and we do that for quality care. Our medical records tell a story. They tell the story for each position, looking at the record so that patient can have an appropriate continuity of care as they go through the health care system and the only way that ourinsurance companies know how we are doing, how we are performing is through the documentation and the coding. That is our communication tool to our providers and to our payers. And so, as we move away from E. And M. And P for service. We go into this value-based approach, where we are showing the quality of care that we are providing how sick our patients are, and really justifying the costand the the amount of money that we take care of.

Daniel J. Marino:

Really and really tracking all the activities of really what has occurred with that patient, not just within that particular encounter, but really from a comprehensive standpoint, everything that's happened to them over, say the the duration of their care, if you will. 

Dr. Shah, how have physicians reacted to this? Do they see? that the improvement to some of their documentation. Not just improvement to some of their coding. But you know, with, Sarah said, being able to tell the full story, has this been something that they have been open to? Or has this been a challenge that they really needed to overcome? 

Dr. Shah:

Yeah, I think this is a really hard shift, you know, when you think about the ambulatory setting, you are talking about limited amount of time with patients who may be coming in for a multitude of illnesses. 

 Maybe that really needs some special attention to one or 2, and you are being tasked with capturing and documenting on all of their chronic illnesses. You couple that with the ambulatory space. We are really still focused on E. And M. Coding fee for volume and not really fee for value. I think it is a hard hurdle to overcome. 

I think what is really important, though, is when we are talking to our providers is, this is really the next phase of how we deliver care to our patients. It is really how we keep the lights on and get the equipment that we need to take care of them. And so, just as if there was a new drug for a chronic disease management that was having really good outcomes. We would all be excited to start prescribing that medication. We should be excited about the opportunity to really convey the quality of care that we are providing through our documentation. 

Daniel J. Marino:

Yeah, I agree. That is a great point and I cannot help (inaudible) you have been practicing for 25-35 years, right? Because they are used to really (inaudible) And now, all of a sudden, we are taking in these other elements into consideration. And so when you started your program and you started to really introduce this where did you start? Did you start with a couple of, say, disease categories like the chronic diseases? Or did you start with a segment of the population? you know, Dr. Shah! from your perspective what made the most sense for the physicians. 

Dr. Shah:

I think what really is helpful was starting with the why and really laying the groundwork. For here is why HCCs are important in our population health strategy. Here is what an HCCis. Here is how it impacts the reflection of the quality of care that we provide.By the way, it also impacts reimbursementand then we coupled that with some very basic tools in our EMR, and then from that, from that kind of just foundational understanding, we have added educational modules. We have added the ambulatory CDI process that you alluded to. And so that is really sort of been an iterative process of starting from a foundation of understanding why something is important, and then providingmore and more tools and support and feedback to our clinicians about how they are doing and how they can improve.

Daniel J. Marino:

So, Sarah, when you started to consider some of the tools. And again, I am a huge proponent of technology, right? We have talked on this program many times that in order to really create efficiencies, you know we have to help our physicians work smarter, help them, not work harder, but become more efficient. Obviously, the technology and the tools help with that. 

 Where did you start? What are the tools that are out there that help support them in improving a lot of their documentation?

Sarah Hartley:

This is still a difficult thing, because tools are limited with the. 

Daniel J. Marino:

It is in the early stages of this. 

Sarah Hartley:

Right. So, we look to our Ehr, that is the main tool that our providers use, and the goal is to make it as easy as possible, reduce the number of clicks and the number of steps they have to take, and really embed our process into their day to day workflow. And then what can we help? What is the benefit that they are getting from us.So we looked at how the alerts fire in the Vpa. Can we make sure that those are accurate and we can add information in there for them to address the Hdcs with their patients. We have separated out thequeries that we send to our positions because they get jumbled up in the rest of the messages. And what are the templates looking like? Do we have that phrases? Are there other tools in the Ehr that can be very easily accessible. That kind of help, the provider drive the elements of that documentation.

Daniel J. Marino:

Yeah. And really help them become more proactive. Right? I mean, you see this all the time. One of the reasons why physicians I think it's so frustrated is becausethere's just so much work that they have to do, and it is a lot of redundancy that certainly that they donot need to do, or somebody else could do, or they have already done it. So they are in baskets are huge, I think, as you start to put in place. What I'm hearing you say, is kind of those activities to help support the documentation activity will help them become a little bit more proactive and hopefully less inthe burden. Dr. Shah,Is that been kind of a benefit that you have seen from the program?

Dr. Shah:

I think absolutely. And I think one of the really important parts of our program is that we are going to our clinic business meetings on a regular basis, and hearing feedback and sharing opportunities for improvement in many of the times we do are able to take that feedback back to our team and think about, how can we make something better? How can we make something easier for a clinician. 

How can we educate in a different way? are there ways to make this sort of come alive for our clinicians in a way that they are going to remember what we are saying to them. But I think that engagement is key. You cannot just set it and forget it with any improvement effort in quality, any quality, improvement effort. But I think, especially when it comes to documentation, which is added work on top of the work of caring for a (24:47) you have to be able to go back and provide feedback and say, Hey, I listen to you, and here is something cool that I can offer you, or Hey, I completely hear where you are coming from. I'm practicing clinician as well. And here is how I navigate this space, and how I am able to be successful.

Daniel J. Marino:

But what I am hearing you say though, is under the clinical documentation improvement program that you have in place. This is not just enhanced coding right? But it's really enhancing what is being documented being proactive and aligning it with the right level of coding. But understanding sort of what else has to occur right? Even outside that clinic visit. Is that correct?

Dr. Shah:

I would say it is really less about the coding and more about the documentation we can get to the codes. If the documentation is there. Physicians are not coders. We should not be. We end up, you know. That is not where our brain space, should be spent. 

 But we are experts at taking care of our patients, and we are experts at communicating to our patients how we are going to take care of them where the work needs to happen is translating the into the electronic medical record so that others can see how we are taking care of our patients. And then as positions. We get the credit for the work that we have done.

Daniel J. Marino:

Yeah, yeah, what has been the adaptability on this? I can imagine that this had to be really tough. When you first to introducethis right?I'm sure you have gota few scars and a few bruises. You probably both do. What was the adaptability of this? I mean, Did you find that physicians understood it, and that they were able to, you know, they sort of embraced it, or did they come to the meetings, little kicking and screaming, and saying, Oh, not really sure what we are doing. Or maybe this is just one more thing we have to do.

Sarah Hartley:

I think it's a mixed back.At the end of the day,our physicians are human, and it's hard, right? And so you have to speak to where they are at, and that in person, presence, and having those ongoing conversations has really helped taken the program to another level, where we have much more engagement.

Dr. Shah:

and I would say, the other part is that there are going to be people who are excited about it. There are going to be people who are able to see why this is important. And I would grab on to those people. Cultivate your excitement, you know. Bring them formally into the program. You know we have a team of physician advisors who are all very passionate about this. And I think it's something that sets our program apart. But if you find someone who is asking great questions, or sharing great ideas. Cultivate that enthusiasm as much as possible.

Daniel J. Marino:

Oh, yeah. Well, excitement like that, I mean, that's contagious, right? I mean, that's what kind of takes off. 

 If you're just tuning in on I am Daniel Marino, you're listening to value-based care insights. I am here with Dr. Shah and Sarah Hartley. We are talking about ambulatory clinical decision programs, key to navigating through value-based contracts. And Dr. Shah, as you were talking about that. I guess a couple of other thoughts came to mind. As you were thinking about the adaptability here. Did you incorporate this, or have you incorporated this in any type of financial incentive? In other words, if you have been able to achieve better performance on your contracts, have you included this within your incentive distribution model or rewarded physicians for higher adaptability, or something of that nature?

Dr. Shah:

We have included this as a part of our bonus metrics in primary care as well as in our medical group and some of our specialties as well. We understand that this is more work for all of our clinicians, and we want to reward them. 

 We want to make sure we are doing so in a compliant way, though. So that is why our program exists. We are really focused on the I in the clinical documentation integrity, you know, acronym. And so we are not just rewarding people for clicks and for adding diagnosis. We are doing it for adding accurate diagnosis and supporting the documentation. 

Daniel J. Marino:

Well, at the end of the day, I mean, those are the key drivers, because sometimes you can see, this is just like you said, adding more clicks or adding more codes or more diagnoses, or what have you and that have some impact to risk, and the wrap, score and all that stuff, which is, I guess, all good. But the end of the day. That is not going to get you where you want to go. We need to make sure that the risk score is accurate. We need to make sure that the patients that we are seeing and how we are seeing them either with the in the clinic or the referrals is efficient because it affects the cost of care. We also have to make sure that utilization is as efficient as possible. So I agree with you. I think the integrity piece is really key. and I think wrapping that within the incentive program. That is how you really really create some strong momentum. 

Sarah, when you have all started to align this or thought about this with the contracts. have you been able to see that the performance of the contracts, the connection between what the physicians have done, improvement in the documentation, so forth. Have you seen greater performance or alignment with the contracts and with the payers in a way that it's helped. Maybe the discussions you are having with the payers or something in that regard. 

Sarah Hartley:

Yeah, so I think the key one of the keys to being successful in this space is having those relationships with the payers, and we have monthly meetings with each of our payers, and we are seeing improvement. We are seeing our raft score increase. We are seeing a recapture rate increase year over year. you know, we are seeing our annual wellness visits increase. And so there is definitely an improvement as we move forward.

Daniel J. Marino:

Yeah, yeah, I can see that. So what about the challenges? I mean, I imagine this cannot be easy.Right? This is, you know, cannot be easy at all. It'sa paradigm shift, like we talked about. We are introducing new things. Sarah, from your perspective. What has been the biggest challenge that you've had introduced the program and now have worked through the program. over theselast period of time.

Sarah Hartley:

Oh, we are boiling the ocean here, I mean, we are just kind of scratching the surface. and you know primary care is a great place to start. But our specialistsreally have that knowledge to get us to that next level code that is really specific. So how do we get them engaged. We cannot put everything on primary care. How do we please? Every pay or all of the contracts are different. The report is different. We do not even get the same information from each payer. Do we have all of the claims data, right? And sothere'sall of this lag and these nuanceswith our metrics. With the data we receive. We have limitations with the technology. It’s every aspect, I will tell you. We have a challenge. It's with dapping. We firmly believe in trainingfrom the ground up because we are not going to find seasoned ambulatory Cdi staff. And so we bring in people, and we train them from the ground up. And we have been very successful with that as well.

Daniel J. Marino:

Yeah, that's great. How about from your perspective, Dr. Shah whathas been some of the biggest challenges that you have seen?

Dr. Shah:

I think the biggest challenge is that it is very hard to show the value of the work that is done in a way that feels immediate to a provider. It is really easy to say I treated your diabetes, and now your A1c is under better control. That's good for you as a patient, and it's good for me for my quality metrics. 

 When we talk about the reimbursement or the benefit that comes from Hcc. Capture and documentation. There is a huge lag like, Sarah said. It depends on what the contract is, how much it does. It depends on where the patient was seen and how that money gets distributed, and then at the end of the day it does not necessarily come back to an individual physician, so I think it is hard to convey to a provider. 

 Please trust me, this will have a benefit for us in the long run. and we have been lucky that we have a lot of folks who just kind of take us at our word, and we have to prove to them now that all of this effort is worth it 

Daniel J. Marino:

Yeah. Connecting the dots I think is always the hardest, especially in value-based care. When you are thinking about what your performance looks like. A lot of times you do not see that financial reward until after that performance here, and in most cases it is even 4 or 5 months after that because you are still going through all of the reconciliation. So you know, and in a lot of cases we are asking physicians to trust the process to get us to where we need to go. 

How has physician leadership come into play? You have mentioned that You had rolled this out to a number of physicians, and Sara had mentioned primary care and kind of rolling this out to the specialists. 

 Have you relied on more of the rank of file physicians within your network to drive this? Or have you really focused on creating? maybe working this through the leadership of your network. 

Dr. Shah:

I think we have really gone at it from both ways. You know, leadership engagement is so important for sure. And so we want to make sure that across the board that our leadership understands why this is important. But a leader alone is not going to get us where we need to be to support individuals. We need to support folks who are in the trenches and doing this every day. And so, while it is important to rally the troops when it comes to leadership and make sure that they can spread the messagesupporting and kind of cultivating. success really comes from our physicians who are doing this on a day to day basis. 

Daniel J. Marino:

Yeah, absolutely. Well, I can only imagine, this is a (inaudible) in terms of how we are dealing this thinking about changing the care model, as well as enhancing the documentation and being able to modify that culture, you have to relyon your leaders. But you also have to rely on good performance outcomes. Right? You have to measure your success as you go along. Sarah, have you? You know I would assume you have come up with some pretty good reporting, or at least some data, at least some information as a feedback tool, right that you can provide to your physician, your leadership?

Sarah Hartley:

Yeah, yeah, we do. We have very manual reporting at this point.

Daniel J. Marino:

the annual reporting. My goodness.

Sarah Hartley:

Yeah, yeah, I mean, we are. This I'm telling you in the industry. And we were just yet, we are not alone in this space. So, but using industry best practices like Http recapturing or query response rate is showing our providers that they are doing the right thing. We do measure wrap internally our risk adjustment factors for. And really, that is just directionally, because as you said earlier at the end, you know that 18 months ago, Today we are getting our raft score from 18 months ago. So you know, you cannot really see that. But it is directionally showing up.

Daniel J. Marino:

Yeah, yeah, I can see that. And you know I was kind of joking when you were saying Manual. You recaptureate the awv percentage. All of that, I think, becomes really key.  

But I think the system still are quite antique, right? As you start to really look at how, what the physicians are documenting, and is it accurate? Right?

Sarah Hartley:

And the population that you are measuring is very important.It is a subset of your overall. You know patient population that is just in these value-based care contracts. So you have to be very careful.

Daniel J. Marino:

Well, ladies, this has been great, I tell you, and I give you a lot of credit for embarking on this in a way that it sounds like you have built some good collaboration. And you know, understanding that it is a journey. And it is not going to happen quick. But it is something that is extremely important. 

Doc Shah, for any of our listeners, and I'm sure there's quite a few that are really giving consideration to putting an ambulatory clinical decision, improving the program in place. What advice would you give them? 

Dr. Shah:

So there is a quote from Wayne Gretzky that often gets thrown around when we talk about value-based care. You probably said it on this program before, but you have to get to where the Puck is going. You are not going to be successful if you skate to where it's been. And so I think you have to start talking about Hcc. Capture and documentation as part of your population health strategy.As soon as you identify the need to have a population health strategy, I think it's also really important to cultivate expertise amongst the folks who are going to be talking about this. I think on the surface of it. Hccs can seemreally easy, and it's really easy to understand. I capture this condition, and I put down some documentation, and I'm good to go but once you really delve into it, there is a lot of nuance, and, as we know, increasing scrutiny as well, and so you donot want to be in a position where you havenot enough depth of expertise to back up the work that you are doing.

Daniel J. Marino:

And I that is so critical and helping physicians particular understand why this is important and what the value is.Sarah how about from you? Any thoughts? Any piece of advice you can give to our listeners?

Sarah Hartley:

Do not be afraid to take a chance, you know a pilot is where you begin, and that is how you know,You just gotta get your couple of physicians to buy in and work with them and the pilot is the way to go. But have no fear.

Daniel J. Marino:

Yep, got to start somewhere. Right? Because I've said time and time again small and impactful. So you are right. Well, this has been fantastic. If any of our listeners are interested in, maybe reaching out to you.Have a few questions. Sarah, any thoughts on how they can get a hold of you?

Sarah Hartley:

Yeah, you can reach out to me. I am on Linkedin. So, Sarah Hartley,search for me, and I am out there. Please feel free to send me a message. Happy to chat.

Daniel J. Marino:

Good Doctor Shah. 

Dr. Shah:

Same thing. I'm on Linkedin. Purv Shah. Happy to connect with anyone out there. 

Daniel J. Marino:

Good! Well, thanks, guys, I really appreciate it. Good luck to you as you embark on this. I would love to have you back, and maybe another, you know, 6 months or so to see how your how you're doing, and I'm sure you're going to have quite a bit of success. So thank you for joining the program today.

Sarah Hartley:

Thanks for having me.

Daniel J. Marino:

and for our listeners. I want to thank you all for listening in until our next insight. I am Daniel Marino, bringing you 30 min of value to your day, Take care.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners

Many issues are impacting today’s clinical service lines, especially cardiovascular services. Health systems, hospitals, and physician groups are focusing on growing their cardiovascular service lines to address shifts in site-of-service, improve patient access, and position themselves for enhanced financial performance under value-based contracts. 

In this episode of Value-Based Care Insights, Daniel J. Marino talks with Dr. Hani Salti, a clinical cardiologist and Clinical Assistant Professor at a large academic-based health system.  Dr. Salti shares his insights on the growth of cardiovascular service lines, the need to develop strong physician leadership, and the growing impact of cardiovascular services on population health.  

KEY TAKEAWAYS: 

• The cardiovascular service line drives tremendous clinical value by creating a comprehensive longitudinal care model that includes general cardiology, invasive, and non-invasive services.
• New financial models will align incentives and modify behaviors of cardiovascular physicians, providers, and payers.
• Value-based performance will have a sizable impact on cardiovascular services creating financial opportunities.

LISTEN TO THE EPISODE:

 

 Transcript:

Daniel J. Marino: 

Welcome to Value-Based Care Insights. I'm your host, Daniel Marino. In today's episode, we're going to spend some time talking about cardiovascular service lines. As I've mentioned in previous episodes, hospitals have focused a lot of attention, on expanding their capabilities in different service lines. 

Some hospitals and health systems and even some physician groups have spent a lot of time expanding primary care, service line, orthopedic service line. But cardiovascular service line is interesting in the fact that it touches a lot of different subspecialties and incorporates a lot of different areas of needs within the patient populations, if you will. 

And there's been a couple of real drivers for that. I think one is that as our population starts to age, cardiovascular services is an important element that patients are looking for to continue to, allow for a healthy lifestyle. What we're also starting to see is that, as we start to advance into population health and we track our outcomes and we look at social determinant factors, cardiovascular care is a natural progression that patients are looking to really begin to manage around. 

Payers are looking for it in terms of being able to track a lot of our outcomes, and it does provide a pretty strong economic opportunity. Four hospitals, four health systems, and frankly, for physician groups. Well, to continue the discussion today, I am really pleased. To have a great guest joining me today, Dr. Hani Salti, he is a physician with a very prominent cardiovascular group, has worked in obviously cardiovascular services in in all of his career, but he brings a very interesting perspective to our conversation today. Not only is he involved. In the growth and the direction of cardiovascular services of his group. 

But he's also very involved in a lot of the population health and value-based components related to cardiovascular care as well. Dr. Salti, welcome to the program.  

Dr. Salti:

Thank you for having me. Please to be here. 

Daniel J. Marino:

So, Dr. Salti, when you think about where cardiology, where cardiovascular care has gone, boy, it's madetremendousamount of leaps over the years. Reflecting back, what do you see are some of the biggest changes that has affected you, your colleagues? I guess the specialty in total.

Dr. Salti:

There have been a lot of changes over the years and it, this is an ever-changing, service line and product. 

And I look back to even my medical school and my early training years. I was in Michigan Medical School in University of Michigan and, Northwestern for training. And if you think about those times, these were hubs, tertiary care hubs where patients would come to from all over the state and sometimes from all over the country to see a particular specialist, whether it's in cardiovascular care or any other specialty. 

And they come, they get their service there. They may stay for a period of time, even in the local geography, and then they go back to their locales. And over the years, some of the earliest changes is where institutions are bringing the care more to where patients are and so the geography has become different in terms of where the care is offered what the patients have to do to access that care. 

And that's just to begin with.

Daniel J. Marino:

right. I agree with you. You know, I've had the opportunity early in my career, I've worked with a pretty large integrated cardiovascular group and it's always been a specialty that's been near and dear to my heart. I provided a lot of practice administration for the group, and you are right, we set ourselves up for a destination center. 

And now it seems like. Through a lot of the advancements of technologies, through a lot of the advancements of therapies and so forth, care has become a lot more localized. But what I'm also seeing, and I would be interested in hearing your thoughts on this, it used to be that cardiovascular services, the interventional side was very transactional based, right? 

So a patient became a candidate for surgery, we immediately put them in surgery, and then they transitioned out. Now within cardio with cardiovascular care, it's very integrated, it's managed, it's focused, so as a patient becomes a candidate for cardiovascular care. They're monitored. There's a lot of therapies. 

The interventional side almost becomes, I don't want to say a last resort, but it's certainly not the first resort of treatment as we begin to think about that. And, and so it's really expanded the whole dynamics of what cardiovascular services really is. How has your group really responded to that? 

Dr. Salti:

It’s absolutely a reality and a challenge that every group has to deal with and it's actually every group has to embrace and this actually speaks to the comprehensive care of the patient. The patient does not come and see you just to get a procedure and to go through the procedure well. The patient wants to be healthy, to have good outcomes to live life the way, the way they desire. And so this is not simply taking care of them, it is not simply about performing a procedure and having a good outcome of the procedure.  

So even our outcomes are not measured based on procedure complication rates or success or failure, our outcomes based on how are patients doing overall. Are they even satisfied with the care just in terms of patient satisfaction and so it's a com and then the services we have to offer them are not have to be comprehensive. They cannot be a successful service line, you need to be able to offer the patient the full scope of what needs to be offered to them in various situations, whether it's procedures, including surgeries, whether it's cardiac, rehab, preventative care, devices for electrophysiology colleagues. And so you have to take them and be able to take them through the entire journey as they seek care from you and you deliver it.

Daniel J. Marino:

That is such an important point, and I would even go so far as to say that is a really a primary critical success factor of building a successful cardiovascular service line. You need to have all of the subspecialties integrated, right? So, they're working together and managing the patient where they are as the patient's risk, condition and complexity needs change. 

And, you know, when you think about it from a value-based care population health perspective. You're measuring really the outcomes over that of that patient over time. But if you do this well and you have clinical pathways and protocols that you're able to measure, you will significantly impact the overall cost of care, and at the same time provide an incredible experience to the patient.

Dr. Salti:

That's very true. And for somebody delivering the care you need to understand the patient as they come to you. What is their risk? What are their comorbidities? What other diseases interact with each other? So, population health, tremendously valuable. To be able to understand it, utilize it in, in all your decisions, so that you understand the person the patient as they come to you in their entirety. 

And of course, that's tied to outcomes, payments, reimbursement, which in turn feeds back to your, to your experience as a provider delivering that care. Yeah I absolutely agree. You know, one of the challenges that I often see as I work with A number of different service lines not just cardiovascular services, but access is an issue. 

Access is an issue all over healthcare, whether it's primary care, it's, you know, cardiology, cardiovascular services, whether it's orthopedics, it seems like, you know, there continues to, to not be enough physicians, not enough providers, and yet the needs are certainly there in delivering that care to the patients. 

How your group responded to some of the access changes and really the needs of the patients? One response is what I was touching upon earlier, which is you have to expand your geography. You have to meet patients where they're at geographically. You, you should not expect them anymore to come to you. 

And this is not just in cardiology, I mean patients. Patients press a button and expect a car to come pick them up, right? Or, or press a button and expect the food to come to them. And it should be no different in healthcare. They, they want the healthcare to be where they're at and to meet them where they're at. 

And so, to make yourself available where the patients are available is very important and then you have to make, you have to understand your referral patterns. Some of them are their traditional, you mee the primary care doctors. You have to build relationships with them or other specialties. 

But also sometimes, we we're seeing more and more self-referrals, right? Study the various entities that are supplying care in their area. And they're choosy. They may choose a primary care doctor in one institution and see a specialist in another institution simply because of either reputation or what they offer or where they're at. 

Daniel J. Marino:

Right. Or convenience for that matter.

Dr. Salti:

Convenience. And you have to remember, a lot of patients are not even seeing the traditionalprimary care.They’re getting their services in alternate locales, whether it's at the pharmacy even. So how they come to you is different and you need to meet them where they're at. You should not expect them to adapt to what you want, how you want them to behave. You need to, you know, be available for them.

Daniel J. Marino:

That is such an interesting point. You know, an important point too, the paradigm shift I think is we are, we all are, are going through right now to provide more convenience based healthcare services is something that is, is critical and patients are asking for that, you know, and, and some of the subspecialties, I think we tend to focus more on that traditional way of delivering care where we want the patient to actually make the appointment and come to see the physician. 

But you are spot on. You need to have a lot of different types of opportunities to connect with the patient, whether it's through telehealth or it's through other types of conversations, or be open to the fact that, you know, patients may be self-referring and, and so that relationship with the patient versus the relationship with their PCP.  

Frankly, maybe a little bit different  

If you're just tuning in. I'm Daniel Marino and you're listening to Value-Based Care Insights. I am here talking to Dr. Hani Salti. We're discussing the advancement of cardiovascular service lines and Dr. Salti's perspective on what makes for a successful service line. 

Great discussion. Dr. Salti, as I think about the value-based care component of this an area that I think is always a little bit of a challenge is as we start to think about really aligning the patient with their primary care. Many patients that are within cardiovascular services see their cardiologist as their primary care physician. Right. And cardiologists are internal medicine trained and many of them do a fantastic job of providing primary care services. How do you manage that within your group? Do you assume some of that primary care responsibilities for the patient helping you to kind of manage the total complexity and needs of that patient? Or is your preference to send them back to the primary care physician and maybe have that collaborative working relationship with the pcp? 

Dr. Salti:

I think as a group, our preference is to have a collaborative relationship. Having said that, we have seen all the whole breadth of how patients perceive cardiology.

Daniel J. Marino:

Yeah, I can imagine. Sure. 

Dr. Salti:

Yeah. And, and some of our maybe older cardiologists who have been in practice decades and still may function like that in certain situations. But then generally, and I think that's true for most is we try to encourage them to have a relationship with to keep the relationship with their primary care doctors. 

And if they don't have it because they saw you primarily without a referral, we definitely encourage them to establish the relationship with the primary care doctor. 

Daniel J. Marino:

Yeah. And I do think that'sprobably the preferred approach, right. You know, to really create that alignment and, and from a value-based contracting standpoint, you know we're constantly looking at who the patient is attributed to and really putting together a very collaborative, very comprehensiveapproach to managing that care, not just for cardiovascular services, but if the patient has say, you know, a GI issue or orthopedic issue or whatever the case may be, it's, it's coordinated through the primary care.So that makes a lot of sense. 

Dr. Salti:

Yeah, absolutely. And, and, you know, population health is not an individual effort. You can expect Exactly A particular specialist to capture the entire popul risk of your patient and let alone the whole population. So, it is a team collaborative effort with multiple, of course, primary care, but all the specialists have to participate in capturing their respective, you know, conditions of the patients and documenting on it. 

And so, it has to be a collaborative effort for it to be successful.

Daniel J. Marino:

Yeah, great point, great point. I absolutely agree. You know, when you, when you look at cardiovascular care over the last couple of years we're seeing a lot of pressures to shift a lot of the care that's being delivered. Mostly the interventionalists or procedural type care. 

You know, a couple years ago, a vast majority of it was done in the hospital, on an acute basis. More and more now is being shifted to the ambulatory setting or the outpatient setting. How has your group dealt with that? How have you managed that transitions that that undoubtedly have occurred?

Dr. Salti:

So, it's a challenge. It's a and again, challenges have to be embraced. Absolutely. But it's, it's a challenge and so it's about number one access. So again, you have to shift some of the services to ambulator, which enhances access to the patient, but also you need to be able to deliver the same quality of care in all these settings that you're, that you're at. 

So, and that's true. Not just on the provider side, but even. A patient may come and have an, have an echocardiogram performed in an offsite versus in the hospital, the quality of that echocardiogram needs to be the same, right? And, so you need to train your sonographers, you need to train the, the support staff to, to be able to deliver the same quality and the same experience with the patient wherever they meet you.  

Right. And that is a challenge. You know, we talk about practice variability among providers and physicians, but there could be practice variability in how even our support staff is able to support that care.  

Daniel J. Marino:

Oh, absolutely. And I think that level of training, at least initially, is different, right? 

I mean, there is some training that has to occur more on the outpatient arena. And just making sure that the investments in the equipment are there and you know, just the overall focus and attention is really given to the ambulatory arena. I think it's easier to accommodate that in the hospital because it's more just the philosophy, the mentality is

Dr. Salti:

Yes. And, and even administrative staff are present. Yeah, mostly in the hospitals. They see what's happening. They can see what's on the ground, what's needed, but to have a fully functioning Offsitethat's able to deliver the same quality and you know that that site needs to be function independently and  

Daniel J. Marino:

No, I agree with you. So, if you, you know, given where your group has gone and some of the, the upcoming challenges or changes that are undoubtedly occur, we talked about many of them here today. 

You know, the, um, Let's say the impacts of population health and value-based care shifts in the site of care from acute to ambulatory. Um, you know, managing, working with the different providers and managing the care more, you know, collaboratively. So forth. Where do you see the big growth opportunities occurring for cardiovascular services as you sort of, you know, look at your crystal ball and think about where things might go in the next couple of years?

Dr. Salti:

So, first of all, the opportunities are always there. The patients are living longer.  the cardiovascular disease still remains, you know, the number one prevalence. And so the population, the opportunity for growth is there. You need to be able to meet it with access, comprehensive care, quality care. 

The scope of care that you deliver and you need to be able to build all those elements that can support, your care. Whether it’s, the interventional side, the structural side, the heart failure side, the EP side, preventative, weight management, cardiac rehab. And so the growth will be there as you support those services, but you need to be able to invest, in those services and ensure that you deliver that you have access. The patients have access to them and you deliver it with good quality.

Daniel J. Marino:

Yeah. And all those elements tied together, like you said, taking advantage of. Where the, you know, the environment is going and the reimbursement elements and so forth. You know, as you're thinking, as you were kind of describing that we've had an opportunity to work with a number of different service lines at cardiovascular service lines, has been one that we've worked with quite a bit, and we've done a lot of strategic development, a lot of areas where we've developed strategic plans and so forth. 

And you really do have to think about cardiovascular services and the service line as its own separate business, right? Where are we going to grow? How are we going to be able to take the care out to the community? And even how we're going to market ourselves, right? Creating ourselves, branding ourselves around high performing cardiovascular services. That recognition and connection with the patient becomes really powerful. And as you kind of think through all the elements that you just talked about, building that into a strategy that really allows you to gain a lot of momentum and really see a lot of opportunity for growth.

Dr. Salti:

And once you acquire a patient and allow them access into your system, there's a big trickledown effect into multiple divisions within your organization. Be, you know, a cardiac patient will touch multiple, aspects of your division, whether it's radiology. Cardiovascular surgery and vascular are of course almost automatic, but renal, endocrine and diabetes,  support, whether it's oncology and hematology and coagulation issues, vascular medicine, pulmonary and critical care. 

So, you are supporting the services then offered by all these other specialties and so a successful cardiology service line is, In instrumental in the success of an entire organization.

Daniel J. Marino:

Yeah. Boy, that is an absolute great point. So, any of our listeners today, you know, that are tuning in, that are interested in expanding their cardiovascular service line maybe kind of reaching out and connecting with some of their community providers.Is there a couple piece of advice that you may offer some of our listeners today in terms of where they are and maybe where they need to go?

Dr. Salti:

You know, I think it boils down to the basic access quality, scope of care delivered, be able to be, be available, do-good work, and be able to, to provide what the patient needs. 

And once you work with these three elements, You can scale them up to your capability and time allow, but that's where, yeah, any, anybody can start.

Daniel J. Marino:

Well, I agree with you and the, you know, one of the things that's always fascinated me about cardiovascular services is, you know, it touches so many different areas of the healthcare continuum, right? Not just in terms of what happens in the hospital and the ambulatory, but certainly expanding to post-acute and care in the home, which there's a lot of focus on, but it also integrates a lot of the providers and the providers’ support. So, I think reflecting back on those three elements, access, quality, the scope of care. 

For an organization that really focuses a lot of attention on this, there is a, there, there's a tremendous opportunity for you to expand the amount of services, expand your breadth of reach to the community, as well as then be able to contract around it. 

Dr. Salti:

Correct? Correct. And, and, and you'll be able to lift up other aspects of your, of the organization you're working with as you do it successfully. 

Yeah, absolutely. Well, Dr. Salti, I want to thank you for coming on the program today. You know, it's been a great discussion as I mentioned, cardiovascular services. I'm doing a lot of work in this area right now. It's always an area that has been near and dear to my heart, and sounds like you've done fantastic in your group. 

So I'm very excited for your direction and I'm particularly excited about how you're taking a population health. Value-based care approach to it because again, as you know, on value-based care insights, that's an important element that we try to share with the group. So, I commend you for, for really thinking through that a lot. You're doing a nice job.

Thank you very much. Pleasure to be here. And yes those are all things we cannot forget about and more to come. This is the beginning of our journey. Not the end yet.  

Daniel J. Marino:

Yeah, absolutely. Well, for our listeners today, I want to thank everyone for tuning in. Great discussion on cardiovascular services. And as Dr. Salti mentioned, you know, it really comes down to thinking through what the strategy is. Thinking through what the approach is, dealing with access, dealing with your collaboration with your physicians, so on and so forth. I want to thank all of our listeners again for tuning in until the next insight. 

I am Daniel Marino, bringing you 30 minutes of value to your day. Take care.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners

As more and more provider organizations engage in risk-based contracts, including Medicare Advantage, understanding  quality and performance along with clinical workflow integration  is critical to contract success. On our third episode of our three-part series focusing on risk-based contract and performance, we invited two special guests from qrcAnalytics to join the show and dive deeper into Risk Adjustment Factor (RAF) scores and the impact of Hierarchical condition category codes (HCCs).  

Tune into the latest episode of Value-Based Care Insights, as our host Daniel J. Marino speaks with Gene Rondenet and Paula Gallagher on how data and information critical to proactively build a prospective risk model is key to to manage the potential risks of health care cost increases and prepare the organization for the future. 

KEY TAKEAWAYS: 

• A prospective model provides the organization with a forward look into actionable data to affect change in the organization for better care outcomes.
• All key stakeholders, including providers, must be aligned to attain the goals of better care, lower cost, and improved care outcomes.
• Provider organizations must prepare for new, evolving payment models and learn how to navigate the intersection of quality, risk, and cost.

LISTEN TO THE EPISODE:

 

 Transcript:

Daniel J. Marino: 

Welcome to Value-Based Care Insights. I'm your host, Daniel Marino. We are very excited about today's episode. If you've been listening to the last couple episodes this is a third part series where we've dove into discussions around risk-based contracting. The first episode was a replay that we did with my colleague, Cliff Frank. It was initially recorded last October, and we spent some time talking about the foundation of risk-based contracting. Episode two is where we brought Cliff back. And due to the fact that there's been a lot of changes with regards to risk contracting, particularly in the MA space CMS made some new announcements. Cliff and I spent a little bit of time talking about what some of those changes are and how providers need to reposition themselves for success within risk. And a big element coming out of that conversation was the need to really create sound models, really moving from retrospective to prospective models and understanding data, the performance outcomes, all of those things that are going to drive change for providers in the clinical setting.

Well, in today's episode, we're going to dive into what that data means, what the models really should look like, moving to a prospective risk model. At the end of our conversation today, I have a really exciting announcement to share with everybody that I am really looking forward to, to making some real changes and, and support with a lot of providers within the industry. So, with that being said I have great guests today. qrcAnalytics is an analytics firm. We at Lumina have done quite a bit of work with them over the years. They have lot of expertise in in extracting a lot of clinical data, claims data helping organizations prepare for risk monitoring, the performance of risk-based contract. Here today to talk with me is Gene Rondenet. Gene is the founder and president of qrcAnalytics and his partner in crime, Paula Gallagher, vice President of Sales and marketing. Paula and Gene, welcome to the program.

Paula Gallagher:

Thank you. Hey. Hi, Dan. We're excited to be on.

Daniel J. Marino:

Paula, let's start with you. You know as we've talked about, risk-based contracting has really changed. A lot of providers have started to really build their capabilities on understanding RAF scores, understanding quality, understanding HCCs, understanding where they need to, what their information needs to look like as they're optimizing some of these contracts. What are some of the things that you've seen as real challenges to providers to ensure their success as they've engaged in these risk-based contracts?

Paula Gallagher:

From my perspective, going into an organization, I'm kind of an early adopter into the organization when they're getting ready to move to more downside risk. And one of the challenges I have as I am prepping an organization to get ready to work with qrcAnalytics is letting the organization understand the data that is needed to take a full holistic look at the organization. We need administration buy-in, we need physician buy-in, we need revenue cycle buy-in, we need h i t buy-in. And working with organizations so that they understand this holistic view of data and how to apply it to the rest. Right.

Daniel J. Marino:

And really plotting that course, right. So exactly. If they're at risk, you know, and again, there's upside risk and there's downside risk. Nobody wants to payback a check. Everybody you're focusing on performing, you really do have to have that full buy-in. But I also feel like you have to have a clear understanding on what informs what, what the information that's needed. And in order to get the information, you have to have the right level of data. So, you know, Gene, I know you've spent a lot of time, you've worked with large health systems around the country. I'm building these models. In your opinion, are providers capturing the right level of either quality data, performance data, claims data or is it that they don't have it, or maybe they just can't extract it and make sense of it?

Gene Rondenet:

I think the biggest challenge is getting the providers to understand the difference between their clinical workflow and what the financial needs of the organization are as far as revenue. And understanding the connection between the two that the physicians are, you know, they're clinicians, so they're looking at things clinically, but they put things into the visit note that represent what they're doing accurately, but then making sure that there's a connection between what's in the visit note versus what is updated in the problem list, what diagnosis codes get captured, and making sure that those things all tie together and making sure the right level of specificity on the diagnosis codes. And that's becoming more and more important as the newer models are coming out, that the CMS is requiring that necessity. If you don't provide it, you won't get reimbursed. Right.

Daniel J. Marino:

And it needs to be presented in a way, I would think that it has to translate to the clinical workflow, right? So as you're getting this level of information, like I said, it needs to be incorporated into the problem is incorporated into the care plan in incorporate it into the conversation that these physicians are having with patients. So you can really make that change. But Gene, I immediately then go to the concept that we've talked about moving from this concept of retrospective information or modeling to being prospective, right? So understanding what we need to do going forward to drive that change. I think moving to that prospective model, that's a necessity in my mind of the success of these contracts,

Gene Rondenet:

Correct? Yeah. The pro prospective model is much more efficient for within the clinical workflow, and it's much more accurate. Everything just works much better. You know, like we said, it requires the entire organization to be bought into the process. And it's really, really important before you take that downside risk that you use a retrospective model to try to train the organization to what is coming. And so right when you look at the visit notes and you have your auditors look through the notes and say, what was missed? You know, what was documented, but not quite close enough that we can't capture properly and use the opportunity before you're taking that downside risk to kind of get the machine well lubricated and functioning properly. And then when you get to the, so when

Daniel J. Marino:

When organizations make this change from retrospective to prospective again, they're extracting their own data. I sort of think about retrospective and I had a conversation with a vice president managed care just not too long ago, and they were almost a hundred percent relying on the payers to give them this information and really understanding what their performances and then trying to apply it going forward. And I said, well by the time the payers give you this information, it's too late, right? Yeah. You need to have these models, you need to put them in place ahead of time. So you're able to drive some of the change in your opinion Gene, what's some of the data that's required, or what's the data that is required in order to build this prospective risk models?

Gene Rondenet:

Really the single most important one is having the ability to see what HCC diagnosis were previously captured for a particular patient. And if they're not acute, making sure that those get captured on an ongoing basis. You know, they have to be captured every year. And one of the best ways to manage that is using the problem with, and making sure the problem with is accurate as all the HCCs diagnoses that are appropriate, and then using that to drive as new visits come along. And then also using algorithms when a patient comes in to see if there's any clinical indicators that there's a potential HCC diagnosis that hasn't been captured yet. Then you also being more prospective if you will, using AWS as an opportunity to capture HCCs preparing for when a visit is scheduled and this about to happen, and making sure you have enough information to support that. But one of the biggest ones is identifying patients that have not been seen. Right?

A lot of times providers are more passive. A patient shows up, but the organization needs to be more active in looking forward and say, okay, I've got patients who were at risk for and we haven't even seen them. So, A. you're not capturing the diagnoses that you should be getting reimbursed for, and B, you're not managing those conditions. And so that is the big win on a on this kind of a contract. If you're managing the patient properly, you're getting paid for the risk. And so if you manage it properly, you're making money.

Daniel J. Marino:

Absolutely. Absolutely. And, and that's such an important point, but it's really comes down to making sure you're extracting that right level of information. And as you said Gene, it's the HCCs, the diagnosis, the problem list, and so forth. Paula thoughts?

Paula Gallagher:

Yeah. You know, the retro Gene is being awfully modest about that, that first step of making sure that the inform the data is accurate, because it can take our organization a while to verify that the information coming out of a health system is accurate. And when we look at the retrospective, it also gives us a little eye into possible training needs and into possible areas where the organization might be needing additional assistance to get where they need to be before they're taken downside risk. And this isn't an easy process by any stretch.

Daniel J. Marino:

Right.

Paula Gallagher:

And making sure that data is accurate.

Daniel J. Marino:

Well, that kind of brings me to my next point. As I was thinking, you were describing this Gene, there's been a lot of focus on the RAF score, right? I think early on a year and a half ago, folks spent a lot of time thinking about how to create accuracies of the RF score. And again, I think good, bad or indifferent, possibly some providers have maybe overemphasize the support or the calculation of the RF score, but it is an important driver as you are thinking about how to create that true care directed support to patients who need it. Paula, as you think about the RAF score, as you think about providing that right level of support, how do you position it appropriately so the AF score is accurate? So you're actually able to drive a lot of change to the patients within the clinical setting?

Paula Gallagher:

The first thing that we would do with an organization is we try to assess where the organization is, and we take a look more at the HCCs than the RF score. You can't really change a RF scores, you can really affect it by the HCC. So that's really where we really pay attention to. As Gene had mentioned, if they're being properly assigned to diagnosis, how they're working with their HCCs to really be able to affect the organization's overall scoring to make sure that it's compliant and that it's accurate and that they're getting the appropriate reimbursements for the population they're caring for.

Daniel J. Marino:

Yeah, absolutely. If you're just tuning in, I'm Daniel Marino, you're listening to Value-Based Insights. I'm having a great conversation today with Gene Rondenet, Paula Gallagher from qrcAnalytics, and we're talking about the data needs, the modeling requirements that are important on driving a lot of these risk-based contracts. So Paula, just kind of building on what you had just said, the capturing and recapturing of the HCCs is critical, having the data elements both I think in terms of the claims data and the quality data is really important. But at the end of the day, we have to create these level of reports, these insights, if you will, to really drive clinical operational change with the practices, right? Because if it can't translate well to the clinical workflow of the physicians, then I, I think many of these providers are going to be challenged in really performing well in these contracts. Would you agree Gene? thoughts?

Gene Rondenet:

Yeah, I think that what Paula mentioned is a really important point that from a clinical perspective, you know, as a clinician mindset, they don't think about RAF scores. It's just a number. It doesn't mean anything to them, but if you tell them they need to recapture diabetes, that makes perfect sense to them. And so we really try to focus more on the actual recapture of the diagnosis code that is the HCC.

Daniel J. Marino:

Right? Absolutely. So let's focus a little bit on some of these audits and things that are coming down from cms. There's been a lot of discussion lately related to the increase in the amount of audits, increase in amount of, of activity that that's going to occur from CMS and possibly OIG and so forth. How are you working with your clients right now on to support some of these audits to ensure that there's a level of compliance?

Gene Rondenet:

Yeah, we try to make sure that they have an internal audit process that predates any kind of RAV audits or any other kind of repair audits, or things like that so that they understand it where they will land if there is an audit, make sure that the organization is well trained to understand the accuracy of coding based on the clinical record. That’s the essence of what an audit is. It’s basically looking at the claim that was submitted and the diagnosis codes, and then the clinical documentation to support that. And so we have a process where they go through and do those, you know, mock audits, if you will. Even though they check type in our audits, because, you know, at the end of the year, you do have to attest that your claims are accurate. And so going through an auditing encounter is a sampling encounter for providers on a periodic basis. It is a really good idea to figure out who needs to be trained and how to code no code, how to write their notes so the coding is appropriate and making sure that the organization follows those guidelines.

Daniel J. Marino:

Well, and I'll tell you, this is a part that has always been important to me. You know, we've done a lot of revenue cycle work over the years and have helped many organizations with their compliance program. And I know you all have done a great job on building these risk model compliance. I'm looking forward to working with you and on really creating a strong risk model compliance program that kind of incorporates the right level of modeling with, as well as a lot of the policies and procedures and the elements that are going to be critical on supporting providers in the event that they are audited. Because I think it's always scary. And as we've talked about before, Gene, it was as long as they've been able to demonstrate that they have the ability to self-monitor and self-governance selves, that goes a long way towards, ensuring that level of compliance. Paula, let's kind of change the discussion a little bit. As we think about where contracting is going, Medicare advantage, some commercial risk-based contracts as hospitals are starting to consider taking on additional risk. Are there two or three things that are top of mind that are really critical that these providers need to think about or really give strong consideration to as they build the right level of modeling, the right level of data, and the right level of reports?

Paula Gallagher:

Absolutely. And when I talk to organizations that are still primarily fee for service moving to valued based contracting and eventually to downside risk, we encourage, the sooner they assess how they're capturing HCCs, the better. If you're not taking downside risk, it, you don't have the compliance issue and the deletes and the returns, you can still work pretty transparently with organizations to make sure you're doing it correctly and accurately. And then from there you can decide what are the best contracts to participate in based on the maturity of your organization and move along an appropriate path so that you have a sustainable model for caring for patients, and that you can continue to get the appropriate revenue again, to care for your patients because you're going to care for them regardless. Right?

Daniel J. Marino:

Right. And these contracts build on one another. As we've negotiated managed care contracts for many, many years, and the fee for service side and the fee for value side, I often say as you're negotiating the first this contract, right, you have to think about the next contract, even though you're not negotiating for it. But how is this contract going to impact the future contract? And typically, when you're managing this fee for value contracts and taking risk, you're only going to be asked to assume more risk. Yep. And, you know, Gene, I guess I'll throw this back to you. As we're thinking about the data, and as we're thinking about where these risk-based contracts are going, from your perspective, what do the payers really have to consider as they're negotiating these contracts that are critical elements on driving this success?

Gene Rondenet:

Well, one of the things the payers would like to get is more clinical information, but that's generally problematic. And that's why it's nice to have an organization that sits between the payer and the provider organization that can have access to the clinical data to run out. Yeah. So that there isn't the privacy issues and we can actually dig a lot deeper than the payer. But then getting the payer to give you the provider organization access to data that they have that you don't have is critically important and the time to do that. And when you're negotiating the contract, one of the things we love to see is if we can get the payer to say, these are the HCCs that we see that you have captured, so that we understand to make sure that everything's in alignment. That, you know, we thought an HTC was submitted, then they didn't recognize it, and we need to know why. And so it's very important to kind of close that loop, and they're generally a little reluctant to do that. And so it's been somewhat challenging, and that's the best time to do that is during contract negotiation.

Daniel J. Marino:

Well, some time ago, it reminds me Gene, of that comment that you just mentioned. I was part of a panel that we were working through manage care contracting, and one of the facilitators asked a question to me and said, when you're talking about collaboration and sharing of information with a payer, what are some of the key things that are important? And as I sat back and thought about it, in my mind it came down to three things. One, the provider has to have good sense of their data, right? They have to have a strong model, they have to believe in their data, and in some cases, the information, in most cases, the information that they get really has to be better than what the payer gives them.

And they should be able to get that because they have access to the clinical data. Correct. Second to that is you're going to get data from the payer. We have to use that data as we get from the payer as a tool to develop our under understanding and drive change, not really as a defense mechanism. And a lot of times, providers will jump to being defensive because oftentimes the information we get from the payers is sort of less in terms of the financial implications than what we as providers think we have. And then third to that, as you're thinking about either the financial reconciliation or the performance going forward, you need to take both the data that you're getting from the payers and your own model and really evolve that for future change, both in terms of the contract that's going to be important going forward, but also in your clinical setting. So really understanding the model, the payer data, operationalizing that, those are really the three key things that I found that have been absolutely critical to performance.

Gene Rondenet:

Agreed. Yeah, just following the entire life cycle of the data provider organizations collect it, they send it to the payers. The payers either deny or pay a claim or set the reimbursement. Then figure out why they set the level at what they set it at and making sure you're all in agreement.

Daniel J. Marino:

Absolutely. And I think if they do that, that's what's really going to allow providers to be successful on these risk-based contract plus allow them to again, mitigate some of their risks going forward. Well, at this time in the show, I'm really excited guys to make this announcement. I know Paula, Gene, this is something that, you know, we've been talking about for quite some time. We've been working alongside each other for quite some time. So to our audience, I'm really pleased to announce that Lumina Health Partners and qrcAnalytics are coming together as a program collaboration. The title of the program is going to be qrcIlluminate. It's an integrated program of data analytics, risk-based modeling combined with clinical and operational change, with the goal of driving true performance improvement and optimization, true success from a lot of these managed care contracts that providers are undertaking. I personally am really excited for this. You know, in Lumina we've done a lot of contract negotiations and have done a lot of clinical redesign. We've not had access to a data partner. Working with qrcAnalytics has been fantastic. And you know, Paula and Gene, I know you've sort of struggled with some of the operational things as well. So any thoughts that you can share? Paula,

Paula Gallagher:

We are super excited about this. I've been wanting to do this for a long time because I was very excited to be able to bring an organization data that they can use to drive change and operationalize, particularly the contracts. It's a tricky lift, and I think it ultimately having better outcomes and better care is of course, that is our goal for anybody working in healthcare for the most part. And I think this will be a really great partnership to be able to deliver on that.

Daniel J. Marino:

Well, and I think the exciting thing is that we're going to be taking a lot of the expertise and the knowledge that we have in, in value-based contracting and really pulling together a strong data engine around that, right? That's coming up. Yeah. You've been doing that for years, but now to really begin to operationalize some of those key elements, not only are going to help organizations really succeed and optimize their contracts, but it's going to help them to kind of think about what's it that they need to do next to ensure that they're going to achieve that success going forward. Gene, any thoughts?

Gene Rondenet:

No, we're very excited to do it too. And just to be able to take kind of our nerdiness and, and mix it with work with organizations is going to be very powerful.

Daniel J. Marino:

Yeah, I agree. I agree. Well, to our listeners, if you're interested in learning a little bit more about qrcAnalytics, their website is qrc-analytics.com. And of course, our website is luminahp.com. Stay tuned for even more information about what our combined integrated program is going to look like. And again, it's called qrcIlluminate. Really excited about this. And of course, if any of our listeners are interested in talking more about it, learning a little bit more, understanding what the value would be, feel free to contact me directly or Gene or Paula as well. Paula, I don't know, maybe if you want to give your email address, it might help some of our listeners.

Paula Gallagher:

Sure. It's Paula.Gallagher@qrc-analytics.com, if anybody has any

Daniel J. Marino:

Sure to our listeners, you're going to be hearing a lot more about this. You know, Gene, I think certainly given your expertise, you're a wealth of information. I think as we start to continue to work together, continue to support providers you know, I certainly want to continue our discussion and even talk about some of these other top of mind issues that will come out related to risk-based contracting.

Gene Rondenet:

Yes.

Daniel J. Marino:

So let me start again. I'm going to build off of that. Gene, I don't know if you have any final comments you want to put in. I was kind of tossing over to you.

Gene Rondenet:

Not really. Paula usually comes up at that <laugh>. Okay.

Daniel J. Marino:

All right. So I'm going to do a signing off then.

Paula Gallagher:

Yeah.

Daniel J. Marino:

To our listeners, I want to thank everybody for listening in today. Again, these three episodes, I think were just great conversations. I would encourage folks to go back and listen to them. And again, if anybody has specific questions on qrcLuminate, happy to answer them. Until the next insight, I am Daniel Marino, bringing you 30 minutes of value to your day. Thanks and take care.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners

For the second part of our three-part series, we invited Cliff Frank back to discuss the changes among risk-based contracts. Daniel and Cliff explore the pushback with RAF scores, new CMS announcements with potential health equity indicators, and much more.

Listen now to our latest episode of Value-Based Care Insights, as our host Daniel J. Marino and guest, Cliff Frank, dive further into value-based contracts and what has changed over the last few months.

KEY TAKEAWAYS: 

• New regulations are making it harder to risk-adjust certain conditions, particularly diabetes. 
• The old structure of medical management - where there were a large number of primary care providers referring to a few specialists - doesn’t work well anymore.
• To be successful in value-based contracts, providers must dive into their data and create a model that gives them a better idea of what their performance is.

LISTEN TO THE EPISODE:

 

 Transcript:

Daniel J. Marino: 

Welcome to Value-Based Care Insights. I'm your host, Daniel Marino. This is the second of three episodes where we are talking about risk-based contracting. As we all know, risk is becoming even larger part of a lot of our contracts, especially as we move from fee for service to fee for value. Risk-based contracts, especially in the Medicare Advantage world, is really gaining steam. We talked about that on the last episode, and I felt it was important to rerun the episode that we did last October, where we invited my colleague, Cliff Frank, to come in and talk about the basics of risk-based contracts. Well, I have Cliff with us again today, and we're going to spend a little time talking about what has changed.

And I'll tell you in the contracting world, even though that episode ran last October, it seems like an eternity between now and then, given how much has changed in the risk-based contracting world with the information that has come down from CMS and so forth. For instance, there's been a lot of pushback on the raft scores, on the risk modeling. There was some new announcements that had occurred around the potential health equity indicators that will be part of Medicare Advantage down the road, all of which are really impacting providers and not only our ability to manage according to these contracts or be successful and optimize, , our revenue within the contract, but in particular, what we need our physicians, our providers to do, to move from a retrospective point of care to more of a prospective care model. So, to help us kind of talk through this today, Cliff, welcome to the program.

Cliff Frank:

Thanks, Dan. Happy to be here.

Daniel J. Marino:

So, Cliff, help us make sense of this. What are you seeing in terms of some of these changes? There's been a lot going on just in the last month, month and a half or so.

Cliff Frank:

Well, CMS has been taking a lot of heat from congress and from industry observers that they kind of gave away the store for the last 10 years. So on risk a, on basically uncapped risk adjustment. Now they signaled with some of the ACO products, a willingness to change that in they capped the risk score gain. You could get in a, in M S S P ACOs at 3% over multiple years, whereas it's uncapped in Medicare Advantage until 2024, right? With the new regs, they're signaling that that game is going to end in several ways. First, they're making it harder to actually get risk adjustment. A lot of di they went from ICD nine to I ICD 10 or 10 to 11, I forget which. But anyway, they killed a lot of diagnoses that adjust. There were like 2000 diagnoses, particularly in diabetes. Those are gone. They don't get you more risk points. Then the second thing they did was they said, oh, we're going to really start auditing a lot more closely. And it's not the risk scores have to come in through claims, not through some magical home visit that the plan has orchestrated. So they're really kind of making all that much more difficult, right. At the same time, CMS has signaled a rapidly growing interest in measuring and enticing health plans to tackle health equity. And so as if you kind of think of it as a kind of a teeter-totter, as the health equity side goes up, the risk score side goes down in terms of dollars. So the dollars will still be there, but they'll be there for different reasons, right?

Daniel J. Marino:

So there's really two key things that I've seen. I think it's thinking about how we're positioning ourselves for risk within risk, managing risk, identifying risk within the contracts. That's a big one. And then the health equity piece and where that comes into play. Let's start with the risk piece, because I have a few questions here that I'm kind of working through in my mind. I'm kind of thinking that there's two pieces to this, right? We spent a lot of time as providers talking about the fact that we need to capture HCCs and that HCCs are supporting the RF scores and the raft scores give us a better idea on the, the sickness, if you will, of our population, of which then dollars are tied to that, and a lot of providers who spent a lot of time educating their physicians and monitoring it and almost going back and recalculating that, was that in particular, was it wrong? I mean, did we overstate it? Oh, not at all. Too much focus on this.

Cliff Frank:

That's all good stuff for lots of different reasons. , the first is that, , providers like to compare themselves against each other.

Daniel J. Marino:

You're right,

Cliff Frank:

Yes. And, and so if my per member per month spend is 20% higher than you, of course the first thing I'm, you know, I'm gonna whine about it. Well, my patients are sicker.

Daniel J. Marino:

Yeah. My population's sicker.

Cliff Frank:

Right? So, so the raft scores actually level that, that debate, which then moves us to the next level, which is, well, what are you doing that I'm not doing? What are you not doing that I'm doing? Let's have a conversation about clinical pat use utilization patterns. So you can't have that without some sort of severity adjustment, risk adjustment, population standardization. So regardless of what else happens inside c m s in the deal between the payer and the provider, it's really useful information. Then further to have some indicator as to what's changing in your, in a particular patient, the risk score just jped 30%. Well, there's an indicator for some case management intervention, some care support, some further love and attention from the doctor. , it could be, you know, referral to a specialist, could be any number of things, but it's an early indica, it can be an early indicator of a problem that's common, hard and fast at the member and at, at the, at the provider network,

Daniel J. Marino:

Right?

Cliff Frank:

So, all those things still have plenty of value regardless of what else happens. And then the third is, remember, risk scores can go down. So CMS is isn't saying, oh, we'll insulate you from the down as much as we cap you on the up. You know, if, if you, if you fall asleep on risk scores and suddenly you drop two or three points, guess what you're, and you've got a percent of premi deal, your revenue just went down.

Daniel J. Marino:

You just went down. Yeah. So some of the performance model as well, right? So the performance model still has to be there, right? It still has to be sound, you still have to manage that population around cost of care Yes. Around utilization. Yes. And then you have to accurately identify the risk. I think the key to it though is that you have to be able, you have to connect the dots, right? So if there is, I, if the risk is going up, if the cost of care is going up, and, and even, you know, if it is based on over utilization, as you mentioned, some interventions around care, care, , management has to come into play and you have to show that you're taking some responsibility to, to manage that. I think as we start to think about it, the model has to be clean, but we also have to prepare for some type of audit or some type of realization that this may be questioned, right? So we, we've gotta get back to the data, the model and the clinical performance to be able to show that, hey, what we're doing is, is actually the right thing to be done.

Cliff Frank:

I think all that is true. There's, there are plenty of places for c m s to come look. And, and I mean, it starts with rpm, ccm, telehealth. I mean, lots of new areas that are, have, have been exposed already to some pretty significant frauds. So they're looking, and then, , you have their relationships with the plans, which now cut through to the provider because there's the provider providing the claims information. So they're gonna wanna see the docentation that supports that. Yeah. So if you're just submitting diagnoses with no docentation, good luck. That's gonna be a problem. So

Daniel J. Marino:

Do you think that this is, this is sort of generated from the plans complaining that the risk scores have been going up too much, so they're having to pay back or pay out too much? Or is it that c m s is identifying that, hey, all of a sudden the, the risk severity of the Medicare population has increased? Where is this, where's this come from?

Cliff Frank:

Well, I think it's coming from, from two different directions. One is, yeah, cash out. I mean, the, the, and, and where you see that is the benefit plans that, that, , the, , payers are offering are getting insanely rich.

Daniel J. Marino:

Yeah.

Cliff Frank:

I mean, food gyms , travel clubs, I mean, what whatever you want. Yeah. We'll get and, and a $160 credit on your, on your, premi from

Daniel J. Marino:

Oh yes. Social

Cliff Frank:

Security.

Daniel J. Marino:

I mean, well, in a lot of these premis, I mean, lot and, and a lot of markets, they're not even there. It, there's a $0 premi. They're, it's a

Cliff Frank:

Negative premi. It's a

Daniel J. Marino:

Negative premi. It's a negative. Cause you're,

Cliff Frank:

Cause you're, you actually get a rebate from Social Security. So, , and CMS is looking at this saying, how is this? Right?

Daniel J. Marino:

Right.

Cliff Frank:

So, and the, and, and Congress is looking at us saying, how is this right? When Medicare's going bankrupt and we're, we're kind of paying for all this other, other nice to do stuff. , something's outta whack. And then on top of that, you certainly have the, , the pressure that comes from kind of c m s just being embarrassed.

Daniel J. Marino:

Yeah.

Cliff Frank:

They, they took their, they, they kind of got snookered and they know they got snookered, and so now it's payback.

Daniel J. Marino:

Well, they did. They did. And, you know, it's, it was, there was a lot of pressure around risk. They came up with the, the risk adjustment factor. , and I, I think, you know, they, they sort of connected the dots. Here's how you need to position it. And yeah, they tied a payout to it. So I think initially the incentive was good, but I think it came back to haunt him. Abs. Absolutely. If you're, if you're just tuning in, I'm Daniel Marino and you're listening to Value-Based Care Insights. I'm having a great discussion with Cliff Frank. We're talking about, , value-based contracts and, and really tying that to risk and, and really what's changed over the, the last couple of months. So, cliff, and another question. , how are the payers responding to this? Obviously, there's been a lot of lobbying efforts to Congress to, to change this. You know, we, we, we've read about this. C m s has certainly has responded. How are the payers, how are you seeing the payers responding to the providers?

Cliff Frank:

Well, there is a, an emerging sense of interdependency that did not so much exist before. Providers in 2022 were kind of a necessary evil

Daniel J. Marino:

Mm-hmm.

Cliff Frank:

But now with the data being kind of wholly resting on what providers do and the, and therefore the coding and the, , interventions happening at the physician level, if things don't get better for the member,

Daniel J. Marino:

Right?

Cliff Frank:

They can lose, they can pretty e pretty easily lose the member. I mean, one of the things that's really different is that the old H M O Medicare HMO model of a narrow network focused on a system of care those days, like Kaiser, those days are really hard. Those are hard cells now, right? Most of the product selling are p o go anywhere you want. , as long as it's in, in network and very broad networks. And so, and for zero premi. Yeah. So it's, it's really, , much more member centric. And, and the providers feel that because they're really not in a position to say no, like there's no referral authorization. It's more like they can suggest maybe this orthopod or maybe that facility. But, , if the member wants to go to someplace else, just saw a nice billboard on the freeway, you know, they're going and they may not even tell the primary.

Daniel J. Marino:

Yes.

Cliff Frank:

Well. that's a, that's a different world. And, and frankly, the primaries are, are not up to speed about that.

Daniel J. Marino:

Right. They, they know

Cliff Frank:

Command and control world, and it's not,

Daniel J. Marino:

I had a conversation just a couple weeks ago with, , one of the, the vice president of managed care for this large health system. And, you know, he felt like he was in a really difficult position, vulnerable, if you will, because, you know, they've, , to his, you know, he, he's, he fully admitted, they've not done a good job of creating their models that are prospective. They're, they're mostly retrospective, right? So they're look backs in terms of what had happened and what are some of the trends that have occurred. And, you know, then they're kind of, they're trying to apply that to their contract, and particularly in, in some of the risk-based contracts. And they, you know, they're at risk for 8% premi for some of their contracts. So h he feels extremely vulnerable. And just over the last month and a half, their end of their performance year was a calendar year, the payers came to him and said, here's what your model looks like, right? We're seeing that you overshot your risk levels. We're seeing that, you know, your utilization is higher than what you know, you're reporting that it is. And, and frankly, he admitted he didn't have a good model to begin with. , and they're not making the money that they thought they were going to. And to make matters worth the finance people book some of this ahead of time, <laugh> Oh. Which, which kind of made it a bigger, bigger challenge because, you know, as they were running some of their retrospective models on a quarter by quarter basis, they were playing off the model. Right? Yep. So it, it just, it goes back to show that the data and really moving to a prospective model of risk of care of these care plans, , is gonna be critical to the success going forward.

Cliff Frank:

Well, you just bring up something really interesting that's super important for providers who are in risk deals. You gotta learn how to spell I B N R. Incurred, but not reported. Claims liability and prospective models will help you do that. Retrospective models will leave you blind.

Daniel J. Marino:

Yep. That's what I'm seeing. It can be a 30% swing.

Daniel J. Marino:

Yeah.

Cliff Frank:

And, and you've booked it one way and suddenly you come back and get whacked. Yeah. So, I mean, that can be a real career limiting move for, for a CFO F O or for a, for a, an I B N leader. Yeah.

Daniel J. Marino:

Well, and, and it's really hard.

Daniel J. Marino:

The the point, the question that he had is, you know, where's the truth? Right? It's, it's clearly somewhere in between because he doesn't believe, he doesn't quite believe where the payers are coming in at. And, and certainly he thinks maybe his model was, was off. So clearly it was in between. So there, you know, again, i i, with you, and that's what was my response too, you have to move to a prospective model. It gives you much more, a greater ability to begin to understand what's happening and to influence it, I think is really key.

Cliff Frank:

Well, the other thing is that the payers in this new world are loathed to believe anybody else's data.

Daniel J. Marino:

Well, that is true. Yep. So that is true.

Cliff Frank:

So it almost doesn't matter what our clients think is reality. What is reality to the payer is your r what they think your risk scores are, what they think your expenses are, what they think your I B N R is and all the rest of it. So in a sense, the real effort is you have to, and this is hard. You have to get inside their data better than they do.

Daniel J. Marino:

Yeah, absolutely. Well, and, and our next episode, we're gonna spend some time talking about that. That's the third episode in the series. Because I really feel like if providers are going to be successful, they have to begin to dive into their, their nbers, their data, their models, and create a model that's gonna be prospective one to give them a better idea of what their performance is. But also, you know, in the event that there's an audit, you just have a, you have a lot more capability to be able to respond to around that audit than you do if it's retrospective. , so we're gonna spend some time talking about that. One, one thing that, , one thing that came came to mind, cliff, as you were talking about this, is, , you know, a lot of these models, a lot of the activities of course are, are still wrapped around the primaries. How is this affecting the specialists? Are, are you seeing, , any of the, the, the risk contracts, , impacting the specialists different? Are there things that, you know, the cardiovascular group, , or cardiology or, or some of these other, you know, gi other, these other interventional specialty practices? , anything that they need to do or any impacts that you're seeing there?

Cliff Frank:

Yes. , a lot. , but it starts like three premises up. First of all, we don't have enough specialists. I mean, we already know that we don't have enough primaries, but we've been using nurse practitioners and other urgent cares to kind of plug the gap when it comes time to go see a specialist, it can take four to six months to get a new patient in.

Daniel J. Marino:

I know. And that's outrageous. So

Cliff Frank:

Medical specialist, , neuro, , endocrine, , cardiology. Unless, unless they're, you know, gasping for breath, you know, it's gonna be a problem. Then when they see them, they may, you know, do a lot, may do a little, , they don't really care what the primary wants done. They're just gonna do what they want. Yeah. And if you don't like it as a primary fine, send 'em to someplace else. I got 40 more in the hall waiting to come see me. So the old style of, you know, north American Medical Management where you have a few specialists and a big net of primaries feeding those specialists, and that's all they did, I don't think that model works anymore. No.

Daniel J. Marino:

Agree. I just don't, don't

Cliff Frank:

Think it's very prevalent unless you're Kaiser and you employ them. Right. But short of that, the power dynamic has really flipped. And as a result, oh, and remember, a lot of these specialists are part of private equity deals that are strictly churn and burn.

Daniel J. Marino:

Well, they are. And the integration has to be better. I'll, I'll tell you, it has to be better. , and it has to be, you know, we we're, we keep talking about moving to a prospective risk model that has to guide some of the, the referral activity integration with the specialists, you know, even solvent some of these access issues, because that's gonna come into play certainly as you start to, to think about what the financial performance is going to look like for the network as a whole. And frankly, the payers could care less about, you know, they care from a quality standpoint, I guess, but they don't really care that it takes you 30 days to get into see a specialist. What they really care about is what the cost implications are.

Cliff Frank:

Well, so in Medicare, some of that is diminished because, you know, the Medicare fee schedule is the Medicare fee schedule. Sure. So if you go to the academic medical center, or you go to somewhere down matter street, okay, you may have, you know, , what do you call that? , the, , clinic charges, you know, right. The, the provider based payment problem

Daniel J. Marino:

Cancer charge.

Cliff Frank:

Right. But that gets charged back to your expense. But absent that, , the fees are pretty much similar. So then it's gets to use pattern access and patient initiation. Remember, about half the patient visits to a specialist are patient initiated, not referred by primary care doc. Yeah. These are people who just wake up and they got a sore back, they're going to the orthope right away they go. So, you know, how the heck do you control that kind of utilization if you're the primary care doc?

Daniel J. Marino:

Well, absolutely. Yeah. I mean, and really it's care management. It's that integration piece that has to, has to come into play.

Cliff Frank:

Well, you can't say no. So it's a, a process. I mean, you can't, you can, but you can't make it stick, particularly if the patient's just bypassing you, which is why the care support teams early intervention, , and, and this kind of, right, I don't don't wanna call it disease management because that's not really what it is, but

Daniel J. Marino:

No, there's more

Cliff Frank:

Condition management, there's connectedness to that patient outside of the, the, the doctor's treatment room that keeps that patient coming back again and again, and, and having telephone contact and otherwise informa information seeking so that that relationship can remain vibrant and, , curative. Right. That doesn't happen if it's transactional. No. And if we're paying our primary care doc to be transactional, guess what? We get transactions. We don't get managed care. Right.

Daniel J. Marino:

No, it needs to be managed. It needs to be coordinated. , cliff, we just have a couple minutes left and I wanna get your opinion on, on where some of these contract activities are going. , particularly around what c m s announced. A couple, maybe a, a month or so ago, month and a half when they said, Hey, we're gonna start including health equity indicators as, as part of the contracts real quick, , h how is that coming into play? I mean, health equity, social determinants, everybody talks about it, it's a big driver of, of chronic diseases and so on and so forth. We all get that. But h how are we, how is this this gonna be measured? Any insight you could provide?

Cliff Frank:

Yes. , C D C has come out with a social vulnerability index. C m s has published about 50 measures of health equity from, you know, income and transportation barriers and oth other kinds of, of of things that are, that are, , potential, , , interference with, with access to care. , getting good baseline data is important. The hard part. And, and, and there are companies out there that have big data that can, can do that. Here's the hard part, given that you know that, what's the use case for doing something about it?

Daniel J. Marino:

Well, absolutely.

Cliff Frank:

I'll give you a a an example. Real life last year, big heat wave coming to Philadelphia 115 degrees, we need to know in our A C o, we need to know who's living alone in second story building or higher with no air conditioning, who has C O P D or asthma? Cause they're gonna die,

Daniel J. Marino:

Right? We need

Cliff Frank:

To get and, and we need to get them some fans,

Daniel J. Marino:

Right? So those types of indicators have to be included in the care plan, right? And then as you're prospectively managing that, incorporating that in, so I, which takes

Cliff Frank:

A whole different database, it takes a whole different worldview. And it takes, and that's not something that can come right from the primary care office, really a care management organization, be it a plan, or be it an I P A or an a C o central administration. Somebody's gotta take that view and say, you know what? We need to understand not just the patients, but the whole population and, and apply these various use cases. Right? Now here's the problem. Doctors think from the specific to the general population health, people think from the general to the specific. Yeah. So if you just blop a bunch of stats on the table, the doctor's gonna look down and say, what the hell do I do with this?

Daniel J. Marino:

Right. What does it mean? So,

Cliff Frank:

So really, I think the better way to do it is to take a bunch of use cases like the, like the C O P D patients in a heat wave and work it backwards to some sort of generalized, yeah. This is the kind of information we need. That leap has not been made in the industry. It's wide open.

Daniel J. Marino:

That's a good point. Almost to create pathways around what some of those HE health equity issues are. Well, cliff, , you know, we're, we're at the end of the show. I want to thank you. , you know, I, I think talking about health equity, this, , I, I'd love to have you back and dive into it a little bit further and maybe we can get some data folks in here that have had some experience with, , health equity and social determinant indicators. I think that would be a great discussion. But thanks, cliff, for coming on. As usual. I enjoy it my friend

Cliff Frank:

Time wet fast.

Daniel J. Marino:

It certainly did. And I wanna thank our audience for listening today Until our next insight, I'm Daniel Marino, bringing you 30 minutes of value to your day. Take care.

 

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners

Many hospitals are experiencing increasing workflow challenges due to high inflation rates. As a result, government and commercial payers are responding in unique ways.  

On this episode of Value-Based Care Insights, host Daniel J. Marino discusses economic challenges in health care, particularly hospitals and physicians. We’re joined by commercial insurance and government reimbursement expert, Cliff Frank. 

KEY TAKEAWAYS: 

• Hospitals and other health care facilities are facing a number of challenges, and inflation is a key component to internal issues. It’s essential that providers have an understanding on how to navigate an ever-changing infrastructure. 
• Risk contracting has been a common issue for hospitals as payers are making money on empty hospitals and slower ORs. This obviously increases the need for better contracts between payers and providers. 

• The ACO module has changed drastically, impacting how care is coordinated for Medicare patients. 

 

LISTEN TO THE EPISODE:

 

Since the pandemic, many healthcare provider organizations find themselves re-instituting empowerment initiatives initially created pre-COVID, however, the recent circumstances had a vast impact on the workforce culture. Today, organizations must focus on a transformative culture which allows the workforce members to prosper in their current roles while the fundamental needs of the employees are met. How can leaders ensure this? 

In this episode of Value-Based Care Insights, Daniel J. Marino is joined by Todd Brook and Danica Wasser from Engagement Multiplier to discuss culture transformation and what it takes to have a thriving workforce.  

Key points include:

• The key to workforce engagement is meeting the three basic needs of the employees: physiological needs, safety needs, and a sense of belonging. 
• There is more to workplace happiness than just giving out raises; pay is no longer the only driving component people desire.  
• Obviously, all humans – and workforce members- are different, therefore, leaders must ask pertinent questions and be prepared to act. 
   

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Today, most hospital physicians are experiencing some level of burnout due to increased challenges with greater work activities, high levels of patient needs, and low staffing levels. These challenges lead to a desire for early retirement and physicians looking for new medical-related career options. This has placed increased pressures on hospitals to either ramp-up their recruiting efforts or consider alternative staffing models to support their clinical specialty services.  As an alternative, many hospitals are turning to locum tenens for physician staffing support providing value to the hospital, its workforce, and most importantly, for patients.  
 
In this episode of Value-Based Care Insights, Daniel J. Marino talks with Richard Heim from LocumsPro to discuss some of the benefits locum tenens bring to hospital patients and staff. 

Key points include:

• Recent information shows that 53% of physicians today are experiencing some level of burnout which may impact care delivery.  
• Malpractice and ongoing political struggles are having a negative effect on physician recruitment for hospitals. 
• Personal situations such as maternity or paternity leave, or a desire for work/life balance, may require hospitals to consider alternative staffing in which locum tenens can cover. 
   

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As hospitals and medical groups continue to focus on financial performance, optimizing their revenue cycle through denial management drives results. To effectively reduce denial rates, revenue cycle leaders must first discover the root cause of denials. A focused approach to denial management can provide health care leaders considerable financial and operational improvements.  

In this episode of Value-Based Care Insights, Daniel J. Marino sat down with Tina Hodges and Michael Brown from RSM to discuss some of the revenue cycle challenges facing hospitals and medical groups today, as well as tactics to reduce denials and increase financial performance.

Key points include:

• Health care providers are experiencing workforce challenges; effective management of your workforce is a requirement to enhance the denial management process across the revenue cycle ecosystem 
• Timely data and information allows revenue cycle leaders to understand the root cause of denials and work productively to reduce them  
• Sharing dashboard reports with key performance indicators with stakeholders, including physicians, engages them in the denial management process  
   

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Over the past year, we have seen substantial investments in healthcare made by non-traditional health care providers such as CVS, Walgreens and Amazon and others as they position themselves as strong participants in healthcare delivery.  Last year, 2022, was one of the highest years for health care deal-making with private equity investing considerable resources into technology, physician services and analytics. How will these new deals impact the health care industry? 

In this episode of Value-Based Care Insights, Daniel J. Marino sat down with Brian Greenberg and Zach Eisenberg from Greenberg Advisors, to discuss trends and “hotspots” of investments in health care. 

Key points include:

• Understanding the motivation of private equity as structure investments in IT, analytics and revenue cycle capabilities.  
• How non-traditional healthcare providers are position themselves for growth given the economic and labor for challenges.  
• Trends in investments particularly in behavior health, revenue cycle management and analytic capabilities. 
   

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As health systems, integrated provider networks, clinically integrated networks (CINs), and accountable care organizations (ACOs) engage in population health initiatives, aligning technology with value-based contracts' performance goals is a key success factor. The lack of alignment can be attributed to a disjointed vision, fragmented operations, and misaligned information technology (IT).  

In this episode of Value-Based Care Insights, Daniel J. Marino is joined by Julie Bonello, Founder of Integrate Health, along with Brian Bentley and Nick Frenzer from Epic Health Technologies, to explore how to optimize value-based technologies and drive a higher level of population health performance.  

 

Key points include:

• To drive successful performance of value-based contracts, health care organizations must have an aligned vision, operations, and IT systems, including the electronic health record  
• The structure and leadership of the organization must be led through a clinical lens to achieve results in population health   
• There are critical foundational factors that provider organizations must consider as they adopt technology 
   

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