How Advocate Health Keeps the Value-Based Care Momentum Going

Jacqueline LaPointe:

Hi, this is Jacqui LaPointe, director of editorial at Xtelligent Healthcare Media and the lead writer on RevCycleIntelligence. Welcome back to Healthcare Strategies.

Value-based care. It's something we have all heard about, read about, and talked about, but not everyone is doing it. Even those who are doing it aren't necessarily fully existing in a value-based world. There are numerous barriers to adopting value-based care and reimbursement models from lack of interoperability in accurate data to limited opportunities to participate. Advocate Health is overcoming those obstacles and succeeding. Its affiliated ACOs recently generated $128.2 million in total savings for the Medicare Shared Savings Program this year, the most in the country among integrated delivery networks. What's more, the health system boasts quality improvements from its value-based contracts and the opportunity to do more is still there.

Breaking down Advocate's successes and how innovation can help to achieve value-based care results is Megan Reyna, a registered nurse and system vice president of population health at Advocate Health. Hi, Megan.

Megan Reyna:

Hi. Thanks for having me.

Jacqueline LaPointe:

Absolutely. Now if you could break down a little bit about your organization. Give us some background. What's going on with Advocate Health and value-based care?

Megan Reyna:

Yes, so Advocate Health has 12 different ACOs or CINs, ACOs are accountable care organizations like the Medicare Shared Savings program that you just mentioned, or clinically integrated networks (CINs), which bring together both independent--we call them "aligned"--physicians and employee physicians around value-based care. We have over 2.4 million value-based care lives that we care for within our contracts, and we also have an arrangement from shared savings of value-based care all the way to capitation. We've been in this for a long time. Our clinically integrated network in Illinois, it started really in 1995 with bringing both independent, aligned physicians together around value. So something that is deeply rooted in who we are and really where we feel we need to continue to go in the future.

Jacqueline LaPointe:

Absolutely. As you say, Advocate has been a value-based care leader for years despite a somewhat slow transition, I would say, for most providers across the country. So how does your organization keep the value-based care momentum going?

Megan Reyna:

We need to keep iterating. What we did in 1995 is not the same thing that we're doing now, but really it's keeping the patient at the center of what we're doing. Value-based care truly is around patient-centered care and how we are helping patients manage their chronic diseases, helping them stay out of the hospital. And so it's keeping the patient at the center of what we're doing and then it's also really celebrating our successes and understanding where we have opportunity and trying to drive deep on that and then iterating. So if something isn't working, we've got to stop doing it and we've got to figure out what we can do next.

Jacqueline LaPointe:

Absolutely, and as you mentioned, there've been significant changes, say since 1995, but even since 2012 when you guys first joined the Medicare Shared Savings Program, which is the largest ACO program out there right now. So notable changes, I would say: greater consumerization of healthcare, consolidation for mergers and acquisitions, and definitely new technology advancements just to name a few. But how have your value-based care strategies evolved to align with all those different changes that are occurring in healthcare, specifically in the past couple of years?

Megan Reyna:

So data's at the center of everything that we do. Within value-based care, we need data to really help us drive where we're moving and really what hasn't changed is looking at the data and helping where we have opportunity for improvement. Early on, within our different strategies to move value-based care, those might have looked different over the years, but it's really looking at where we have opportunity, where we have buy-in from those who are participating, and where we can move forward. As the environment continues to change, as the Medicare Shared Savings Program has continued to change, our tactics might have changed. We don't give up on the things that are working, but we need to keep thinking differently about what we can do and technology is absolutely something that also has iterated with us and is something that we continue to look towards to say, not to solve our issues, but really how technology works for us and works for the physician who's seeing the patient.

And that technology has to really help that physician versus be something that's in addition to what they're doing. And so we have to continue to iterate as the technology also gets better, how that helps support the clinicians when they're seeing the patients.

Jacqueline LaPointe:

That makes a lot of sense. I was curious too: how do you guys determine when a technology is a piece of the puzzle for value-based care or improving population health? What's the decision-making process around that? How do you understand when a technology will help you guys?

Megan Reyna:

So the technology is not where we start when we decide we need a new innovation. Really, it's starting with what problem are we trying to solve and then how do we approach that with the people, with the systems that are in place, and then where do we have gaps. And the technology is a tool for us and those tools sometimes need to be updated as well. What we've implemented five years ago isn't what we're always going to continue with if that technology is not iterating with us. The unicorn of all technology is not only interoperability and getting the data to us, but really the unicorn is having that data be interoperable and getting that data back to the clinician and having them be able to use it seamlessly at the point of care.

And that's something that we're always trying to strive towards. I think it's something that we as an organization are always pushing our technology vendors to work with us on and is really important. I think we have a long way to continue to go with that. It's the unicorn still, but it's really where our kind of gold star is and what we look for within the technology that we implement.

Jacqueline LaPointe:

Absolutely, and I think too, there are technologies that exist now. There are technologies that existed then, but what do you see on the horizon for you guys in terms of technology that could help in the near future or are there any strategies that you think might help as you adapt to a lot of different changes going on?

Megan Reyna:

This might get a little wonky and I hope that's okay, but specifically talking about the Medicare Shared Savings Program in the last several years, CMS changed the quality reporting requirements and so by 2025, we need to report quality as an eCQM or a MIPS CQM. That's basically CMS saying you need to try and use this interoperable data to be able to submit the data to CMS for a quality of care, which honestly is a great concept and something that when my peers across the country, when we talk about quality reporting within MSSP, that's where we want to go. We want to do this in a very electronic seamless way, really though, and what I keep personally pushing CMS on is that the technology of us, as an ACO, submitting the data to CMS is not where we need to be and that only really makes CMS's burden, et cetera, less.

Where we need to go and what we are doing and when we're approaching this is how we get that data back to a clinician if we're getting it as an ACO so that they can close a care gap. They can know that this patient already had their mammogram and they can maybe review the results with the patient or they can say to the patient, "I see here that you've already had your mammogram," versus having the conversation about "we need to get the results" and then someone spending all this time to find those results. Data is only going to help that clinician if it is right there in front of them.

And that's really where we need to go with the EMR companies as well, is that this has to be something: the interoperability of that data, them working together and working with us as ACOs to be able to get this data at the fingertips of the clinicians when they're seeing the patient, is absolutely important. And so I am very hopeful that some of these changes push us in that direction because that was ultimately what the country wanted when we implemented EMRs and it just has not yet come to fruition.

Jacqueline LaPointe:

Absolutely. I was thinking too, in terms of what you said about how technology isn't quite there for the ACOs yet, we're moving forward with this more electronic digital quality reporting system. What are some of the barriers that you think exist that are preventing ACOs from really getting the technological infrastructure, specifically that interoperability? What are some of the more general obstacles that you guys face with implementing the right technological foundation to support electronic quality reporting and beyond?

Megan Reyna:

So ACOs, a lot of us have been doing this since 2012, so we have already built infrastructure around our data. I already have a registry for the different ACOs. And with implementing this technology, I think a big barrier for many ACOs was that the technology companies came to us and said, "We have a solution for you." But basically it's this million dollar solution that is replacing everything that we already have in place, and that's not what we need. We need someone to work with us to say, really, "where do we have the opportunity and how do we implement just that?" Because some of us have really good systems already in place that don't need to be ripped out, but we need just this part of the equation implemented. I would also say this has been a journey for several years and I think the EMR companies are really starting to understand the importance of this. I don't want to blankly say all of them, but I will say there are some.

Jacqueline LaPointe:

Absolutely.

Megan Reyna:

I think coming to the realization as well as CMS has passed different legislation as well to help with information blocking and that kind of thing. The reporting and the ease that practices can have with that reporting is also another barrier. So some EMR companies charge practices to collect that data and, really, if they can be a partner with us not to charge for something that really is for the quality of care for patients, that'd be really helpful.

And then there is this other concept in CMS: they have recently, in their proposed rule, offered to have just Medicare patients measured within this quality reporting. Prior to that, it was all-patients, all-payers, and I think ACOs were very concerned that practices that disproportionately saw different patient populations that sometimes quality of care based on different social needs, etcetera, potentially could be asked to be removed from ACOs because quality is served as a gate for that shared savings within the program and if there's ACOs or practices within those ACOs that can't meet an all-patient, all-payer requirement, that [they] would be asked to leave. And that's not the goal of what CMS is trying to do. And I think they've heard the ACOs with that by offering, it's called a MIPS CQM reporting option, which--very grateful CMS did that so that those barriers don't exist anymore.

Jacqueline LaPointe:

It's funny too, thinking about what you said and--ACOs are groups of doctors and other clinicians coming together in the name of quality of care, cost savings, cost efficiency, but also it sounds like there's a lot more partnership going on too at many different levels. We're talking partnerships with your technology vendors, partnerships with the federal government at this point, but definitely other payers. So it really sounds like it's in the spirit of value-based care though, which is really the collaboration and the coordination of care.

Megan Reyna:

And when I introduced myself, we have multiple value-based care contracts. Medicare Shared Savings is a very large value-based care contract that we participate in. But really when a clinician's seeing a patient, they're not always double checking what insurance this patient has. They're treating the patient as they should treat the patient to say, "This is how I provide care." And that's really the workflows [that] we want them to do at the practice. When that patient shows up, when they're trying to outreach to their patients, they're really looking at "how do I care for my patients? How do I care for a diabetic across the board?" Not "how do I care for this Medicare Shared Savings patient who happens to be a diabetic and this is what I need to do a check the box item," right? That's where value-based care could potentially fall down. It's got to really be in the spirit of how we manage patients moving forward to value versus that it becomes a checkmark item.

Jacqueline LaPointe:

I was curious, too, since you guys are a value-based care leader, you have multiple different value-based care contracts. Is it a challenge to juggle all of those, especially where you're standing up certain programs because this population, say the Medicare population, which is covered under the Medicare Shared Savings Program. They need something specific, but maybe you have a different contract with a commercial payer. That population looks a little bit different because they may be younger, maybe a little bit healthier. Is that a challenge to get innovation implemented and executed when you have competing, perhaps not competing, but different priorities?

Megan Reyna:

I would say at a practice level, that's things that a practice deals with on a daily basis, right? If they're a family medicine physician and they're seeing patients who range from birth all the way to the end of life, they are dealing with that on a clinical level. Where we see it from a pop health, value-based care lens is that when you're looking at improvement, sometimes different populations, and so the way that we try to talk about it and work with our clinicians on is different populations of patients might need different types of interventions, but it is always a struggle until everyone's in a value-based care arrangement. Fee-for-service does not reimburse, does not value some of the interventions that we think are highly important to really managing these populations.

Really, when you're digging deep into the data and you're working on something with maybe a hospital operator and an ER physician and a family medicine physician, that's where the data can get into. "It's just for Medicare patients, we're just doing this here. That's what just this," or "I have a larger patient population." And I had this conversation actually yesterday with a hospital president where she said she was having a conversation with a physician where they were working on appropriate SNF [skilled nursing facility] reduction, and sending patients home when it is clinically appropriate, and she was trying to show him some data and he [says], "But my panel size is larger than this," and she was just showing him a Medicare panel size.

And so that's when it can get to, "yes, your population is, but let's look at this through the Medicare lens as there might be an opportunity here," and these patients might need a different intervention than someone who's healthier on commercial insurance because they're in their twenties.

Jacqueline LaPointe:

Absolutely. I was thinking too, on a higher level, what else do you think can be done to support this new vision of healthcare, one that's value-based, tech-enabled, that has more of that focus on population health management versus the strict fee-for-service?

Megan Reyna:

From a perspective of an ACO or an organization, it's really seeing that vision in that future and taking that step forward to participate in these different types of contracts. From a national level, we still have two feet in two different canoes. And CMS is definitely moving us. They have this gold star by 2030 to move all of the Medicare patients into accountable care organizations, and we need to move in that direction. We need to have value-based care as an option. That is something that is a valuable option for clinicians, for hospitals, for systems to participate in.

The thing that I think is beyond that just gold star that we also need to do is certain barriers, or I wouldn't even say barriers, but certain ways that these value-based care contracts are set up really need to not just be checkmark items, but really, like we were just talking about, has to be in the spirit of value-based care. How do we move this so this becomes the way we manage care versus just a quality reporting that goes to an entity to check the box that yes, you're doing X, Y, and Z, or how do we as an entire nation get past some of those technology barriers as well and make this something that we really can have the data help improve our clinicians when they're seeing patients.

Jacqueline LaPointe:

I was curious, too, about that check-the-box mentality that can happen with a lot of these contracts. Is that something, too, that there are data limitations or perhaps quality measurement limitations right now that are preventing that next step?

Megan Reyna:

So there is always, I would say, depending on the entity that is collecting the data, there potentially always [are] data restrictions. But what we try to do as an organization, especially with our employed physicians when we have all of the data in front of us, is how do you measure that, especially quality on an all-patient, all-payer measurement with some of our aligned physicians, those are the independent physicians that are aligned with us on value-based care. We might only have access to their value-based care patients, but we have a significant amount of value-based care patients. And so when we measure on quality, we measure all of the patients that we can measure on quality.

So this isn't just a measurement of just this one contract here, and then you have your other measurement of this contract here, but really what are the systems? What are the workflows? What are the processes that the data is showing us? And sometimes that data is, like, human error. This interface is not working or this physician is entering something in this field versus this field. But those are the things we need to work through and how do we set up the technology so it helps that physician versus telling that physician, "Well, you need to change how you're documenting." Right? That's where we need to go.

Jacqueline LaPointe:

That doesn't tend to go over well, anyway.

Megan Reyna:

It doesn't.

Jacqueline LaPointe:

I mean, we've seen a lot of documentation changes in terms of E&M visits and stuff like that and there's been a lot of pushback. What advice do you have for providers who are looking to elevate their value-based care offerings and strategy? Perhaps they're a little bit behind with some of the technological advancements or they just haven't quite hit the strategy right. Do you have any advice for those type of providers who are looking to move into that value-based care realm?

Megan Reyna:

I always say you just need to take one step forward. There is, and there always is going to be an area of opportunity for us. For us--and I say "us" collectively as a nation--we have a lot that we can work on within the value space. For a physician just getting into this: if you don't have all of the technology, if you don't have everything all put together nicely packaged, you haven't been doing this for several years, it really is taking one step forward. And on our journey, especially in our Medicare Shared Savings journey, the first thing we did was look at our SNF utilization. We are still looking at our SNF utilization, so it's not like we've mastered that. And like I said, it's really about appropriate SNF utilization as well. You don't need all the fancy technology equipment to really look at data and say, "Hey, we have an opportunity here as well."

We definitely, in 1995, [did] not have the nice, cool technology. In 2012, we still didn't have what we have today. And you can really do this by looking at what your data says on an Excel document and saying, "Are we making improvement?" Now, as you move along the journey, you are going to want to implement other technology and other things to really help you make real-time decisions, but don't let that be a barrier to taking the first step forward and you can see great successes that can help you get the capital to be able to implement the technology further by just starting out first, I don't want to say small, but really just taking that first step and saying, "This is where we have an area of opportunity. We can make improvements here, and I can get the buy-in to make improvements here as well."

Jacqueline LaPointe:

It sounds like innovation's going to spring from that data.

Megan Reyna:

It does, and it still is the center of everything we do. It leads us towards where we need to make improvement and what's working and what's not working.

Jacqueline LaPointe:

Awesome. Great. Thank you so much, Megan, for joining us today and providing some insights on this momentous shift to value-based care. Definitely seems like this is where the future of healthcare is going to go, so I appreciate all your insight. And I also want to thank our listeners for joining us. If you have any thoughts on this topic or you have any healthcare-related stories that you'd like [us] to consider covering, you can reach out to me at jlapointe@techtarget.com, that's J-L-A-P-O-I-N-T E@techtarget.com. Follow us on Spotify to get more of these conversations and let us know what you think by reading and reviewing the show. Thanks, everyone. Bye.

*CORRECTION: Article updated to reflect accurate ACO savings.

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