Taking Aim

Northwest Approaches to the Next Generation of Care

In 2008, when Don Berwick first coined the notion of a Triple Aim, little did the general public understand — or even most health care professionals — the impact this simple model would have on the U.S. health care system. Today, it is widely understood that the U.S. health system is the most costly in the world, accounting for 17% of the country’s gross domestic product with estimates it will reach 20% by the end of this decade.1

Change and improvement processes are rampant, and while Berwick’s vision of impacting care quality, population health, and reducing costs still remains elusive to most, the Northwest is home to several organizations aiming in the right direction.

One organization in Vancouver, Washington, is focusing on physician-patient relationships to make a difference. “We want to create a community solution,” says Duane Lucas-Roberts, CEO of The Vancouver Clinic, about his organization’s approach to developing a clinically integrated network (CIN). “Our goal for Columbia IPA [independent practice association] is to create a coordinated approach to quality care, and lower costs at the same time. That goal isn’t anything new, but the way we are organizing ourselves to achieve it is.”

It is easy to notice, as one surveys the region, that as groups organize themselves into CINs, each is doing it differently. Continues Lucas-Roberts, “We see ourselves as just a part of the overall solution. The hospitals are the other part. The patient plays a role, too. But we’re organizing ourselves — starting with the physician and patient relationship. That’s where care really starts and it’s that ongoing relationship that will have the most impact.”

While The Vancouver Clinic develops their physician-centric solution, just four hours away efforts are under way at Yakima Valley Memorial Hospital (YVMH), where the hospital is leading a community-wide charge to create a CIN. But whereas The Vancouver Clinic efforts pivot around the primary care physician and patient relationship, YVMH saw the value of the hospital leading the charge and financing the start-up of Signal Health, LLC.

Headed by Dr. Richard Spiegel, Signal Health has recruited more than 300 physicians, which include all of the hospital’s employed physicians and others (about three-quarters of the total according to Spiegel) that are independent. “If we only deal with the outpatient or clinic side of care, we could hope to reduce emergency department visits, or testing. But we want to look at this as a system — hospital, outpatient, ancillary services. We are all working as a whole toward quality, health, and cost.”

Though the fulcrum of their efforts may be different, they both see the emergency department as a leading indicator of how this new model can work. “In Yakima, there is a culture of first going to the emergency room for care,” notes Spiegel. “In a rural population like ours, culturally, the ED is seen as a place to get primary care. The opportunity for us is not only to reduce the costs of care in the ED, but also to educate patients and change their behavior in how they access care.” One common method being experimented with is the use of urgent care clinics. Physicians at Memorial Hospital, who participate in SignalHealth, have opened up convenient care clinics in Yakima, which are less expensive than the ED — in large part due to the staffing of the clinics by nurse practitioners who cost less than emergency medicine physicians.

Lucas-Roberts recalls his own emergency department challenges while working in Walla Walla, Washington. “Our population was a full-risk Medicaid group of about 2,000 patient lives, most of whom were kids.” According to Lucas-Roberts, this population was running about 1,000 ED patient visits per 1,000 patients per year — about five times higher than the commercially insured population. “We knew we had to change patient behaviors but that ours needed to change first.” The clinic set up a system where the emergency department was required to contact the primary care physician before seeing the patient except in emergent cases. The primary care physician would consult with the patient and either see the patient in the ED, or schedule an office visit. “The result was a reduction in ED visits — from 1,000 to 200 visits per 1,000 patients per year,” notes Lucas-Roberts.

And this is possibly the most compelling and perplexing part of the new models of care — getting patients to change their approach to their own health and consumption of care. The traditional fee-for-service model, coupled with insurance programs that distanced patients from their care dollars, created a multigeneration mindset of how the insured health care system works: Physicians treat, patients consume, insurers pay. This is the model that led us to today’s health care fiscal crisis and one that requires solutions by all parties — with patient behavior now under the microscope.

“Population health management data and analytics is the key to all this,” says Ann Wheelock, CFO of The Vancouver Clinic. But these are not new topics, and something that health care has looked at before. “One of the reasons why IPAs were not successful in the 80’s was that there just wasn’t enough data, or the ability to analyze it like we do today.” Wheelock notes that today’s ability to view patients both individually and as parts of groups, to build and use reports about patient populations, helps to create care and case management strategies that have direct impacts on patient health and lowering costs. “Even the ability to track patient followup is better today than ever before with remote monitoring and in-home visits,” she says, noting that these new ways of delivering care are often less expensive in the long run.

“We have a care management pilot in two clinics and the hospital,” says Spiegel at Signal Health. “We are tracking the high-utilization, highcost patients and providing nurse care and case management. Some of this involves patient education, calls, even home visits. We helped a female patient get better by just helping her to organize and better understand her medications.” The notion is that if you can ensure a patient is taking their medication correctly, using their equipment properly, or even making it to their ongoing appointments, then you will see lower instances of illnesses becoming acute, and chronic patients getting better — leading to patients consuming less costly health care, and less care in general.

But patient engagement and education is not the only answer. Over at Signal Health, Dr. Spiegel is leading the charge to work out standards in how their integrated physicians are approaching disease management, COPD, or other clinical processes. They’re creating a provider portal where physicians can see how they’re doing on quality and cost metrics.

This type of approach also enables Signal Health to look at specific groups and see how they can address population health in different ways, and how the individual providers are doing in working with those patients and groups. “We’re also building a health information exchange as a onestop location for patient information,” says Spiegel. “With this tool, we’re less likely to miss or duplicate prior care, and can track over-utilization of resources. Having this level of data about patient interactions and health outcomes enables us to create performance reports for all our physicians.” And because care utilization and patient health outcomes are linked to payment from payers and physician compensation incentives, this information is transparent to all physicians creating peer-level accountability.

Still, with a renewed focus on patient outcomes, cost containment, and even updating payment models (bundled services, shared risk, and gain sharing), the Triple Aim that Berwick launched faces possibly its most daunting challenge: the projected physicians shortage (mostly in primary care) over the next decade. And there are some indicators that suggest the solution to this shortage may also positively impact cost, quality, and outcomes.

A recent RAND report2 noted that increased use of new models of care could increase patient access to lower cost care, in settings that foster a team approach and higher levels of communication about patient treatment. “Growing use of new models of care that depend more on nonphysicians as primary care providers could do much to reduce the nation’s looming physician shortage,” said David Auerbach, the study’s lead author and a policy analyst at RAND, a nonprofit research organization. The study noted that if nurse-managed health centers were to account for just 5% of primary care offered in the U.S. (currently it accounts for just about .5%), it would reduce the projected physicians shortfall by 25%.

In addition, there’s a renewed focus in primary care medical homes (PCMH), this time with a focus on their application in the commercial space. “Medicaid has used medical homes for a long time with great success,” notes Wheelock. Usually, when patients join Medicaid, their insurer initially assigns them to a primary care physician at a nearby clinic or health center. “Most commercial payers don’t assign a primary care physician (PCP). That’s been out of vogue for both the insurer and the patient. But we want to encourage future payer partners to assign a medical home — it is going to be critical to our success.”

1 Institute for Healthcare Improvement, “The IHI Triple Aim,” accessed May 29, 2014, www.ihi.org/engage/initiatives/tripleaim/pages/default.aspx

RAND Corporation, “Nurse-managed Health Centers and Patient-Centered Medical Homes Could Mitigate Expected Primary Care Physician Shortage,” accessed
June 5, 2014, www.rand.org/content/rand/pubs/external_publications/EP51621.