Stepping Into Accountable Care Through a Health Plan

Making the leap into an accountable care model is no doubt difficult, leaving many hospitals and health systems uncertain if they can survive in a pay-for-performance world. A large part of providing accountable care is identifying and then managing the care of patients with chronic disease. To do that successfully, hospitals and physician groups need access to past and current patient data, which can be difficult to obtain.

Centra Health in Lynchburg, Va., is approaching that accountable care roadblock in a somewhat unique way: through its health plan. Centra started a health plan, Piedmont Community Health Plan, as a joint venture with about 400 local employed and independent physicians in the 1990s. While PCHP, which covers about 30,000 lives, is about 20 years old, Centra is starting to leverage the information gathered from the health plan in a new way to move into the accountable care environment.

Using the data

"If you're going to take on risk, you need to know where to manage care…you've got to have patient data," explains David Adams, Centra Health's chief strategy officer; and Centra has access to patient data through its health plan. Through medical claims data and pharmacy data, Centra can identify which chronic diseases are drivers of high cost and can also identify the individuals who require extensive care navigation or health coaching to achieve better patient outcomes, according to Mr. Adams.

However, with roughly 20 years worth of data to sift through from Piedmont Community Health Plan, Centra needed some outside analytics help and brought in McKesson to install an analytics suite. "We are working on an analytics piece to identify what types of patients and what chronic diseases are driving the high cost of healthcare for our market," he says. "The analytics piece is really the first step" toward accountable care.  

Targeting populations

The analytics tool is able to give Centra retrospective claims analytics and risk stratification for defined populations. "That will give us the ability to allow care managers to target the highest risk patients within the population to keep them out of high-cost care settings," Mr. Adams explains, thus lowering the cost of care while improving patient outcomes through care management.

One of the main patient populations Centra is targeting first is patients with congestive heart failure. Centra is working to install home telemonitoring equipment for patients at high risk for CHF, so home intervention is possible before the patient needs to be admitted to the hospital — keeping admissions, and costs, down. One of the reasons Centra chose CHF to target first is because the 30-day re-admission rates are on the high end, so the system is starting there to reduce avoidable readmissions. "We'll move into other chronic disease as we move into different initiatives," Mr. Adams says.

The future

Beyond giving Centra timely patient claims data to assist in managing the health of chronic disease patients, the health plan also incents the system to invest in other accountable care building blocks. "It gives us the financial ability to invest more in patient-centered medical homes and population health strategies that ultimately keep people out of your high-cost settings like the emergency room that meet the lower cost point of the triple aim," Mr. Adams explains.

Through PCHP, Centra and the area physicians are getting their foot in the accountable care door, but Mr. Adams doesn't see Centra forming an ACO with a third-party payer any time soon. Instead, Centra and the physicians can keep all the benefits of cost savings through its own health plan instead of splitting savings with another payer. "We'd rather see if we can do it ourselves and take all of the upside potential for a local product and local healthcare," he says.

More Articles on Accountable Care:

5 HIT Features Most Important for ACO, PCMH Quality Outcomes
4 Steps Hospitals Can Take to Pilot Bundled Payments
Hospitals, Insurers Devote More Attention to the Cost of Cancer Care

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