The Connection Between Payer Provider Convergence, Rising-Risk and Lucy

January 31, 2018
Mark A. Caron, FACHE, CHCIO, CEO


banner with 42 year old Hispanic woman named Lucy

 

No matter how you look at it, the toll of diabetes and prediabetes is staggering whether you’re the patient, the primary care physician, the employer or the health plan.

  • Nearly 30 million Americans have diabetes.
  • People with diabetes are at increased risk of serious health complications including premature death, vision loss, heart disease, stroke, kidney failure, and amputation of toes, feet, or legs. In 2015, diabetes was the seventh leading cause of death.
  • The daily life of a diabetic includes testing one’s blood sugar, taking medication – about 25 percent will eventually need to add insulin injections, and monitoring diet. Diabetics also are encouraged to exercise.
  • The total cost of diabetes and prediabetes in the U.S. is $322 billion.
  • More than 1 in 3 American adults – approximately 84 million - have prediabetes.
  • 90 percent – or more than 75 million prediabetics – don’t know they have it.
  • About 70% of people with prediabetes will develop type 2 diabetes. According to the world renowned Joslin Diabetes Center, prediabetics “are at increased risk of developing type 2 diabetes within a decade unless they adopt a healthier lifestyle that includes weight loss and more physical activity.”

That’s why everyone involved is motivated to better identify, manage, engage and educate not only people already diagnosed with diabetes but also everyone at risk for becoming diabetic. Patients with a diagnosis of metabolic syndrome – commonly referred to as prediabetes – are one of the cohorts of rising-risk patients everyone wants to identify as early as possible and then engage them in their health to prevent progressing to chronic illness. This is quite the challenge given that the overwhelming majority (90%) of prediabetics do not know they have it.

Earlier identification and management of rising-risk patients is one of the primary reasons payers, physicians and employers are licensing Geneia’s Theon® platform. Predictive analytical models, like those at the heart of the Theon® platform, are able to identify which cohorts of people are likely to become sick in the next 12 to 24 months. But perhaps more importantly, it allows those who interact with and care for prediabetic patients to easily collaborate and align around shared goals and purpose, effectively intervening and engaging patients in a way that improves outcomes and quality of life.

Diabetes takes an emotional and physical toll on patients. It is a burden that includes daily blood glucose testing, medication, more frequent doctor visits, the fear of diabetes complications like vision loss, heart disease, stroke, kidney failure, amputation of toes, feet, or legs, and early death, and more.

Our Vision: Improving Health Through Patient-Centered Care

Let me show you our vision of how healthcare providers, payers and employers work together to improve the health and quality of life for people with metabolic syndrome.


PATIENT

42 year old Hispanic woman named Lucy

Meet Lucy*. She is 42, a mother of two teenagers and a part-time caregiver for her elderly father. Through her employer, Lightning Laser, Lucy has been insured by Allegiant Health Plan for the past three years. The benefit design used by Lightning Laser encourages employees to choose a primary care physician.

Lucy learned of her prediabetes diagnosis last year during her annual physical. In preparation for her physical, her physician ordered a number of tests, including a fasting blood glucose test.

In the year since her diagnosis, a number of people have been working with her and behind the scenes to help prevent her from progressing to diabetes. All of these people are using the Theon® analytics and insights platform to enhance their individual and collective effectiveness.


PRIMARY CARE PHYSICIAN

Image of Dr. Todd Becker, Primary Care Physician

Lucy’s primary care physician is Dr. Todd Becker. For the past 10 years, Dr. Becker has been a part of Granite Physicians, a multi-site practice with nearly 250 physicians. The practice has a value-based contract with Allegiant Health that incents Dr. Becker and his colleagues to complete and improve HEDIS® measures such as measuring BMI, checking blood pressure and ordering fasting blood glucose tests for adult patients. Two years ago, Granite Physicians was purchased by the Be Well Health System.

As a part of the pre-visit planning, Dr. Becker viewed Lucy’s information in the Theon® platform. He saw she was on Allegiant Health’s list of members at-risk for metabolic syndrome and ordered the fasting blood glucose test a year ago that showed Lucy, in fact, has metabolic syndrome. (For more explanation, see section below about the payer HEDIS® director.)

In the year since Lucy’s diagnosis, Dr. Becker and his team have used the Theon® platform to monitor her progress on her care plan, including annual measurement of her BMI and nutritional counseling. Lucy’s referral to Allegiant’s health education program was done within the analytics platform.


PAYER HEDIS® DIRECTOR

Image of a female Jaime who is the Payor HEDIS Director

Jaime is the HEDIS® director at Allegiant Health Plan. At a population level, Jaime works to cost-effectively improve her plan’s HEDIS® performance by simplifying quality measure tracking for network providers including Lucy’s physician, Dr. Becker. For the past three years, her plan has focused on closing HEDIS® measures related to diabetes, including measuring BMI, testing blood glucose levels and blood pressure screening.

Three years ago, Allegiant licensed the Theon® platform to, in part, support Jaime’s work. As a result of Jaime’s use of the platform, she has been able to undertake efforts to identify subpopulations of members with gaps in care, many of whom also are the plan’s rising-risk patients. For example, she reviewed BMI trends to generate lists of members at-risk for or with a metabolic syndrome diagnosis, which were then shared with Allegiant’s value-based care practices. Granite Physicians’ list from 15 months ago include Lucy.


PAYER POPULATION HEALTH CLINICIAN

Image of an African American female Judy Payer Population Health Clinician

Until a year ago, Judy was a disease manager for Lucy’s health plan, Allegiant. Traditionally, her plan’s care management program focused on chronically-ill and catastrophically-ill members. The plan’s increasing emphasis on value-based care and managing the population rather than just the sickest of the sick, means care managers – now called population health clinicians – have an expanded role that includes identifying and engaging rising-risk patients and improving the 25 selected HEDIS® quality measures in the plan’s value-based contracts.

Judy is Lucy’s population health clinician. Using the Theon® platform, Judy is able to monitor Lucy’s progress on her care plan. By viewing Lucy’s record in the Theon® platform, Judy knows her colleague in health education has already reached out to Lucy and enrolled her in the right program. When Judy contacts Lucy, she affirms her participation and answers her questions about metabolic syndrome treatment and prognosis.


HEALTH SYSTEM QUALITY MANAGER

Image of a white female Janelle Health System Quality Manager

Janelle is the quality manager for the Be Well Health System. She works directly with the health system’s practices including Granite Physicians to help them succeed in their value-based contracts. That means she uses the Theon® platform to monitor the practice’s progress towards meeting their HEDIS® quality goals. At the time Be Well acquired Granite Physicians, she used the patient and population insights in the Theon® platform to identify and remedy a systemic gap in identification and management of adults with metabolic syndrome.

Janelle worked with Granite Physicians to create and implement process improvements for closing HEDIS® care opportunities. The practice added another agenda item to their morning huddle: they now review a list of patients coming in the office who have a BMI care gap. Janelle tracked the rate of BMI gap closure over time and found the process improvement was working as intended. Far fewer patients like Lucy have diabetes-related care gaps, and care gap identification and closure is now better embedded into Granite Physicians patient care workflow.


EMPLOYER

Image of a man named Chase who is the Employer.

Lucy’s employer is Lightning Laser. The vice president of human resources, Chase, has been using the Theon® platform for the past three years. At the outset, he focused on out-of-network utilization and preventable emergency department visits. More recently, he has used the platform to identify cohorts of rising-risk employees and learned a sizeable percentage of his employees has diabetes and an even greater percentage has prediabetes or is at-risk for prediabetes. Chase was encouraged by indications from the employee health risk assessment (HRA) summary information available of strong employee interest in improving their health.

Armed with this information, Chase has been working with Allegiant Health Plan to offer virtual health education and nutritional counseling programs, one of which included Lucy, and semi-annual onsite biometric screenings of BMI, fasting and non-fasting blood glucose, blood pressure, and more. Lucy was able to take advantage of the onsite biometric screening this year. Her biometric information was uploaded to the Theon® platform so the professionals monitoring her care plan know she is still on track. Separately, Chase also has adjusted the plan’s benefit design to eliminate the deductible for annual physicals, biometric screenings and nutritional counseling.


For the First Time, Simplified Collaboration and Coordination

I know firsthand those of us who work in healthcare have always wanted to help Lucy and others like her be one of the 30 percent of prediabetics who do not progress to diabetes. For the first time, all of the people who interact with Lucy and have the opportunity to help her adopt a healthier lifestyle and engage in her health – her physician and his team, the population health clinician and HEDIS® director at her health plan, the quality manager at the health system, and her employer - have a tool that simplifies collaboration and coordination in a way that directly benefits Lucy.

I spent much of 2017 writing and talking about convergence, the many factors driving it, the evidence it’s happening, and the tools supporting the change, and I plan to do even more this year. As important as these macro level conversations with industry leaders and policymakers are, I am most encouraged and gratified – and hope you are too – at how alignment, collaboration and personalized, patient-centered care can improve the health, satisfaction and quality of life of patients like Lucy. 

*Lucy is fictional and not intended to represent any specific person. This information is provided for illustrative purposes only.


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