Field Report:  Foundational Steps to Population Health

By addressing change management and cultural needs, SSM Health in Missouri successfully delivered on the move from volume- to value-based contracts and performance.

ABSTRACT: SSM Health has begun the long journey to move from volume- to value-based contracts and performance. The initial step involved expensive software, and the results were unimpressive. By backing up and doing the needed work to address the change management and cultural needs of the physician group, leaders were able to successfully procure and deliver on a risk-based model.

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It’s easy to get too far ahead on the need to accomplish or participate in population health or value-based care. Buzzwords and articles abound, creating panic and feelings of inadequacy. You hear of must-have IT solutions and analytics as antes to the big game. Value-based care is new and exciting, spawning a whole new industry of information technology and tools that promise results. But the real answer is more basic, and it lies within the grasp of all organizations wishing to embark on a new journey: good old-fashioned change management.

The tried-and-true Kotter process for managing change is still paramount to success. Creating urgency for change, forming a guiding coalition of the early adopters, and education are as important today as they were in 1996, when John Kotter wrote his international best-seller, Leading Change. Yet they have been overshadowed by efforts designed to entice the purchase of solutions that will be useless until you do the hard-yet-attainable work of change management.

Care transformation cannot occur in a moment, in a single decision or force of institutional will. While having institutional will is necessary to lead a large group of physicians down a new path, in and of itself it is insufficient. This takes time. You need to start with education and communication. Administrative types are conversant in acronym alphabet soup — MLR, MACRA, MIPS, ACO, MSSP and many others that are foreign and exotic to many practicing physicians. Providers need plain language at the most rudimentary levels to effectively communicate the message.

At SSM Health, our journey began about two years ago. As we mapped out our future, we homed in on basic needs. We focused on the engagement of our providers, the care of the patients, and improved quality and efficiency. These foundational elements will allow us to deliver results in traditional payment models as well as newer risk- or value-based contracts.

We have outlined our early steps in transitioning to effective value-based care. These steps were foundational and necessary. Each was a long and laborious process. Many months of planning yielded a three- to five-year destination and delineated the waypoints on the journey. Given the length of time needed for each project (see Figure 1), they were staggered and started nearly simultaneously. Put end to end, these would cover years rather than months, precluding any near-term capacity for success.

Many physician groups start on long-term initiatives only to fail because of competing interests or the need for quicker results. In today’s fast-paced health care environment, it is easy to skip important steps.

GROUP HISTORY

SSM Health Medical Group , based in St. Louis, Missouri, is a multispecialty group of more than 400 providers, with more than 50 locations throughout the metropolitan area. It has existed for more than 20 years, an amalgamation of three entities. After the merger, each maintained its own governance structures to aid in the transition. Many years later, there was inertia to change to a unified governance platform.

Given this history and structure, there was little communication across geography and little understanding by providers about how to get their voices heard or how to get an audience with administrators. Similarly, the organization had a difficulty finding the right way to get messages to the physicians. These regional structures unwittingly hoarded information and gave gravitas to the physician participants instead of the give-and-take needed for success.

We use Epic Systems software as an electronic tool in both ambulatory and inpatient care. The original installation was in 2005; we recently added Epic’s “Healthy Planet” accountable care and population management module.

GAUGING ENGAGEMENT LEVELS

We needed to engage and educate, knowing that if physicians weren’t part of the solution and development of that solution, it likely would be rejected. To help evaluate where we were having problems, we initiated a physician engagement survey.

The comments and scores indicated that there was a lack of transparency. The physicians did not know how or to whom to voice their thoughts to create change or lodge complaints. We were able to pare most of the comments into one of two buckets: communication and governance. We then facilitated two different groups of physicians, each with about eight to 10 providers to evaluate these areas of concern. After separately meeting every two weeks for six months, the groups homed in on the same solution. The physicians were chosen for their ability to create change and their volunteerism, as well as those who were vocal in their dislike of the current system. If we changed our governance structure, we could positively affect all of the variables we were hoping to improve.

We then embarked on a six-month journey to change our governance structure — to improve education, communication and decision-making that ultimately would lead to better engagement. Previously, the governance model was used to impart operational data, finances and other routine material. Clearly, this type of information was not making the best use of our clinical leaders’ time and knowledge, and it did nothing to advance the foundational processes of care delivery.

Our “novel approach” was to create departments. These departments, as many organizations already have in place, were set up with the expressed purpose of assisting in compensation models, quality metrics, engagement and population health. While not avant garde, their establishment was a big step we needed to take before achieving our goals. The old information model of monthly financials and human resource rules affecting our staff was replaced with physician-designed quality, experience and value-based, forward-thinking agendas.

COMPENSATION MODEL REDESIGN

The lead time for creating a new compensation model can be long — 12 to 18 months for many groups. We elected to simultaneously start a compensation model redesign to allow us to align our incentives and match our aspirations. Because we hadn’t yet completed the governance changes, it was a little clunky. Once the new governance model was in place, the compensation piece moved apace. If we had waited for one to finish before starting the next, we would have added precious time to our transformation, affecting our ability to compete in the new world.

We started with primary care as the focus. Each geographic group had its own compensation construct, so we had to develop a new model while navigating a change that affected three different groups in different ways. The compensation committee was a multidisciplinary group of practicing physicians and administrators with executive support. There was a lot of education and communication. When we started to form a structure for the new plan, we held multiple town halls before going back to the drawing board with the responses. When it was 90 percent finished, we again held town halls for discussion and feedback.

The compensation committee decided on 90 percent productivity (based on wRVU) and 10 percent on quality, experience and citizenship. While we pushed for a higher percentage for quality, this is where the group felt comfortable. For citizenship, the physicians decided that chart completion/closure rate and meeting attendance were important, going a long way toward creation of collaborative accountability that had been missing. Quickly, the discussion from the physicians changed significantly.

PRIMARY CARE REDESIGN

Care transformation begins with redesigning the primary care offices to provide team-based, efficient, high-quality care. Transparent in our efforts to monitor quality, citizenship and patient experience, we identified processes critical to the re-design of a care delivery model for success. Early on, we had certified all 31 primary care sites at NCQA Level 3 Patient Centered Medical Home. PCMH certification is a stringent process developed by the National Council for Quality Assurance that helps to transform a traditional office practice into a home catering to each individual patient’s needs.

During the process, we defined our local care team, established clear roles and responsibilities appropriate to the level of license and linked to standard work. We standardized the rooming process, medication reconciliation and assimilation of outside data obtained via the Health Information Exchange, improving safety, accuracy and completeness of the record.

We then took an honest look at our data and reporting needs and found we could do a fair amount with general in-formation. We also developed an informatics roadmap to align EMR optimization with our value-based care delivery strategy. Partnering with our IT and analytics leads, we quickly established a standard reporting model for administrative contract management as well as detailed provider dashboards showing individual panel performance. A commitment to develop the tools needed to manage patient populations within the EMR led to realignment of analytics tools, installation of Healthy Planet software, ingestion of external claims data and a unified vision of transparent reports delivered to providers via the EMR in real time.

Access is foundational to both growth and management of a population. We embarked on a data-driven, scheduling-simplification process that removed restrictions for visit types, standardized visit length (based on individual physician data) and improved same-day access. We established a standard rooming process for all primary care; currently, we’re scaling it for specialty practices.

To incorporate care rendered outside the walls, we created a strategy for interoperability and made it part of our everyday workflow. This made previously unavailable but critical information available to the right person at the right time. We also standardized the medication reconciliation process to include medications from all sources.

DATA, ANALYTICS AND INFORMATICS

Two years before this change process, our organization had purchased an expensive IT solution that sat essentially untapped. The solution for population health had been an electronic one. Beautiful reports were developed by our administrators, but the mechanisms for sharing, teaching and communication were nonexistent. The data produced was too sophisticated for the rudimentary processes we had in place, and it therefore couldn’t be implemented. Moreover, it focused too narrowly, too quickly and was not amenable to unified management patterns or standard work.

In short, the reports made analysts happy and looked good to administrators but were not truly actionable. We did not need all that fancy data. We just needed some critical pieces and a forum to disseminate, educate and re-evaluate. With this reality, we quickly determined that it wasn’t the right IT solution for us, and we abandoned it altogether.

The lesson learned is that change management and culture transformation are requisite steps. Trying to skip these essentials and moving to a simpler solution cost us time and political capital.

In its place, guided by physician input using the new governance structure, we were able to create high-level dashboards for physicians in quality, citizenship, utilization and patient experience that created an emotional connection to the work. Transformation and transparency helped engender a sense of urgency and active participation.

TESTING THE WATER IN THE RISK POOL

In early 2015, we were informed by one of our Medicare Advantage plans that it wanted to drop our rates significantly or end the relationship because of our high cost and use. We negotiated with them to keep our rates the same but enter into a downside risk program with us. This plan had approximately 7,000 patients. Given its size, it suited us well for our first foray into risk — large enough to mitigate some vagaries of natural variation but small enough for us to man-age effectively.

RESULTS

Using our new departments and standard reporting tools, we were able to quickly get information to the physicians regarding the contract, their attributed patients and our care management program. We were able to lower the medical loss ratio and participate in gain share.

In addition to improvement in the bottom line, we also noted a 17 percent reduction in emergency department visit rates (per 1,000 cases) year over year, a 33 percent reduction in avoidable admissions year over year, and a 10 percent in-crease in follow-up visits after avoidable admission year over year. We always had done a good job of risk scoring and did not see a significant degradation in risk score year over year.

Like most value-based contracts, there is a quality gate that affects the final sharing rate. Table 1 reflects the results we achieved on our four measures allowing maximum sharing.

CONCLUSION

In addition to improvement in the bottom line, we also noted a 17 percent reduction in emergency department visit rates (per 1,000 cases) year over year, a 33 percent reduction in avoidable admissions year over year, and a 10 percent in-crease in follow-up visits after avoidable admission year over year. We always had done a good job of risk scoring and did not see a significant degradation in risk score year over year.

Like most value-based contracts, there is a quality gate that affects the final sharing rate. Table 1 reflects the results we achieved on our four measures allowing maximum sharing.

James Bleicher, MD, MHCM, is regional president for Missouri-based SSM Health.

Peter Schoch, MD, is vice president of value-based care and payment for Missouri-based SSM Health.