Embrace risk: How one clinically integrated network found success under value-based care


Risk-based contracts currently represent a small percentage of revenue for the average provider. However, as healthcare policies push hospitals and physicians to assume more accountability for care, the widespread adoption of value-based reimbursement appears inevitable.

"Today the piece of revenue you have may be small in value-based care contracts at risk — but disruption is coming … and it's going to take delivery model transformation to thrive in this environment," said Mason Beard, solutions strategy leader of Philips Wellcentive, during a July 24 webinar sponsored by Philips Wellcentive and hosted by Becker's Hospital Review.

One provider group that has experienced success with value-based reimbursement is Eastside Health Network, a clinically integrated network based in Bellevue and Kirkland, Wash. The CIN is comprised of 1,352 providers, 185 practice locations, 41 primary care locations, 10 urgent care clinics and four hospitals. While many providers have shied away from assuming risk, Eastside has embraced value-based contracts to transform the way they deliver care.

Eastside's Executive Director David LaMarche and Quality Program Manager Sara Rutherford joined Mr. Beard for the webinar to discuss how Eastside has succeeded under four value-based contracts.

Data: The foundation of value-based care

The transition to value-based care requires a pivot from a sick-care model to a prevention-model, which is impossible without data, explained Mr. Beard.

"Everything from a [value-based] framework starts with that. Data is your foundation," he said. "The second piece is what sort of insights will you glean from that data to change the way you deliver care ... and close care gaps — it all stems from data and insights."

There are several steps to turning data into value-based care initiatives. First, providers must connect data from multiple platforms to establish a cohesive patient record. This data allows providers to gain insights into a patient population and helps discover trends. After digesting the data, providers can begin implementing changes and looking for ways to engage patients and providers in a proactive, population health-oriented model.

Create a population health framework

Eastside Health Network used aggregated data to develop a population health management framework. The framework was designed to succeed under four types of value-based care contracts — incentive-based, shared savings, upside/downside risk and full capitation.

Here is a breakdown of how Eastside approaches two of the contracts.

Under incentive-based contracts, such as Medicare Advantage arrangements, Eastside has focused on closing gaps in care and improving its star rating. To gain insights about which quality measures to target and how to reduce care gaps, Eastside tapped population health management company Wellcentive to generate patient compliance reports.

Ms. Rutherford said the reports function like a registry, bringing together all the "patient cases [and] clearly delineating whether a care gap exists." The reports also show when a patient had their last office visit and if they've received outreach from a team member in the last three months.

Eastside also participates in shared savings contracts, which often overlay existing fee-for-service contracts. The shared savings contracts help to manage transitions of care to prevent readmissions and avoidable emergency department visits. In addition, these contracts incentivize providers to choose a lower-cost alternative drug.

To help manage this strategy and the patient population, Eastside uses high-utilizers reports. The reports identify patients who've had three or more ED visits in a six-month period or two or more unplanned inpatient admissions within the last 45 days, or a combination of the two. The reports allow nurse care managers to ensure patients coordinate with their primary care providers and access care appropriately.  

During the webinar, Ms. Rutherford cited a real-life clinical example of a 30-year-old patient who was homeless and had a history of substance use. He had five ED visits and one inpatient admission within a six-month period. An Eastside care coordinator identified him on the high-utilizer report and reached out to his last primary care provider. The primary care provider then encouraged the patient to connect with a social worker. Since the intervention three months prior the patient has not had an ED visit.

A challenge and a solution

One of Eastside's top challenges was integrating all the data from its 185 practice locations sprawled across a wide geography, explained Mr. LaMarche.

"The challenge for us from an integration of data and … membership standpoint is all of the different EMRs. We think we are north of 100 with all of the different practices," Mr. LaMarche said.

However, with the help of Wellcentive, Eastside has been able to combine data from multiple electronic platforms for one actionable, longitudinal patient record, which has translated into well-informed care decisions.

"This movement from volume to value is going to be an assumed thing," Mr. LaMarche said. "There is an impetus to make sure we take the available [incentive] funds that are present now. We need to be bold in how we approach things, while at the same time being wise about the risk we can take."

To listen to the webinar and find out more about Eastside's risk-based contracts click here. To learn about Eastside Health network, click here. To learn more about Philips Wellcentive, click here.

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