At Geneia, we partner with organizations as they confront the seismic changes happening in healthcare. We help them change the way they work to achieve meaningful population health and succeed in a value-based environment.
Our work with a physician-owned multi-specialty, multi-location practice, which I will refer to as Commonwealth Physicians*, is particularly gratifying to me. Commonwealth Physicians is a growing practice that serves more than 500,000 patients and is comprised of 25 practices and nearly 100 primary care providers. As a result of our partnership, the physicians have been able to remain independent and thrive in the years since the Affordance Care Act (ACA) was enacted while simultaneously improving the health of their patient population.
To read part of one of my blog, visit: Lessons Learned on the Frontier
Data is Queen
In the words of Commonwealth’s chief medical officer, “You can’t manage what you can’t measure.” It was during that initial health plan meeting to discuss an accountable care arrangement that Commonwealth came to truly embrace this idea.
So like many practices, Commonwealth installed an electronic health record (EHR) throughout its practice sites. It quickly learned an important lesson: an EHR is insufficient to manage and improve the cost and quality of care of patients attributed to a primary care practice since so much care, especially for at-risk and sick patients, happens in specialist offices and hospitals.
This realization ultimately led Commonwealth to license its own advanced analytics platform rather than continuing to rely only on data shared by health plans and their timetable for sharing the information. To effect the desired changes, Commonwealth needed Geneia’s Theon® platform and its seamless integration of all clinical and claims information for attributed patients – whether care happened in one of its offices, a specialist’s office, a local hospital or one in Florida. Equally important, Geneia’s analytics platform presents the information in a way that is easily acted upon by busy primary care physicians.
Commonwealth could see the readily-available insights from a peer physician practice – and that validated its decision to work with Geneia. Commonwealth saw that peers could access the kind of actionable information not available from the EHR and that, when addressed, would improve the cost and quality of care. This actionable information available included:
- 10 patients with more than $100,000 in medical costs who had not seen a primary care physician in more than 12 months
- One patient currently in the hospital who had 13 prior admissions as well as more than 200 specialty visits and 150 prescriptions
- A list of patients discharged from the hospital in the past 10 days
- Two physician offices within the practice with significantly higher prescription costs than its peers along with actionable information to remedy the situation
Marrying Data with Clinical Enhancements is King
Commonwealth’s work with Geneia yielded actionable data coupled with clinical enhancements that, in turn, created numerous opportunities to improve the healthcare provided to patients. For example, the physicians combined data with clinical interventions and workflow adjustments to improve colonoscopy rates. They are currently applying the same integrated system to their transitions-of-care program.
In short, Commonwealth calls and ideally sees within 10 days, all attributed patients who have been discharged from the emergency department, the hospital or a rehabilitation facility, whether they are in their home state or wintering in Florida. During the transitions-of-care visits, Commonwealth physicians check in with patients and help connect them with the appropriate resources and programs to support their healing process, including other members of the patient care team.
Creating Care Teams
True population healthcare that maintains or improves the health status of attributed patients requires more than primary care physicians. That’s why Commonwealth created care teams comprised of care coordinators and nurse case managers to better support physicians and patients. With Geneia’s help, Commonwealth subsequently determined it needed a nurse case manager and care coordinator in each office, and that meant reengineering the number of practice sites to house, at a minimum, three primary care physicians in each office.
Creating care teams, in addition to better serving patients in a cost-effective manner, had the unexpected benefit of helping to address physician frustration about the administrative burdens of medicine. Like the physicians in Geneia’s national survey who overwhelmingly said the business of healthcare had changed the practice of medicine for the worse, Commonwealth physicians want more time to create meaningful relationships with their patients and wish to delegate much of the routine, administrative work.
Efficient and effective care teams also require all members – physicians, nurse case managers, care coordinators, physician’s assistants, and even medical assistants – to work to the top of their license. To accomplish this, Commonwealth not only reengineered its offices to support collaboration, but also invested in additional training from The Geneia InstituteSM to enable medical assistants and care coordinators to become more fully engaged members of the care team.
Ongoing Challenges, Future Opportunities
The heart of population health is primary care physicians. The physicians at Commonwealth wholeheartedly believe the evolution to value-based care – one that measures and rewards for quality and cost improvement - is undoubtedly the right direction. Yet much of the burden of this change has fallen on primary care physicians.
That’s why Commonwealth has invested in comprehensive care teams to better serve the complex needs of attributed patients as well as Geneia’s advanced analytics platform to help its physicians more easily measure and manage the metrics they know improve patient health. The practice is also investing in the physicians themselves.
Commonwealth has begun working with Geneia to measure physician satisfaction and address any gaps. Similar to our national survey of physicians, Commonwealth will be ask physicians about the quality time they have with patients and other metrics in Geneia’s Physician Misery Index, including their feelings about the business and regulation of medicine and the ability of data and analytics tools to impact their ability to identify and triage the highest-need patients and create greater efficiencies in office workflow.
To read part of one of my blog, visit: Lessons Learned on the Frontier
*The experience of Commonwealth Physicians is an illustrative example based upon the actual experience of a Geneia client. This information is provided for illustrative purposes only. Commonwealth Physicians is fictional and not intended to represent any specific organization. Any direct similarities to a real organization are purely coincidental and unintentional.