How a CIN shows 'the most significant hope' for improving patient care: 5 Qs with UNC Health Care leaders

UNC Health Alliance — Chapel Hill, N.C.-based UNC Health Care's physician-led clinically integrated network — has worked tirelessly over the past few years to deliver high-quality, cost-effective care to patients as the industry transitions away from fee-for-service medicine to value-based care.

Formed in 2015 with the goal of improving patient care and engaging physicians to succeed in the new era of care delivery, UNC Health Alliance has grown to encompass nearly 5,000 providers statewide.

As President and Executive Medical Director of the Alliance, Mark Gwynne, DO, oversees all aspects of the organization's mission. He works with various independent physicians, provider networks and payers to advance the adoption of value-based contracting to improve care in North Carolina.

Dr. Gwynne said the CIN shows "the most significant hope that I've seen in my entire career to really truly improve outcomes and improve the health of our patients."

Another leader integral to the success of UNC Health Alliance is Robb Malone, PharmD, UNC Health Care's vice president of practice quality, innovation and population health. He worked alongside Dr. Gwynne to build the infrastructure to support value-based care across the health system.

"An epiphany was realizing that as a system you can only grow so much on your own… success will be found in partnerships and developing medical neighborhoods and services in areas that patients need them.  This realization led to the establishment of the Health Alliance and a renewed organizational commitment to improving access across our network," Dr. Malone said.

Here, Drs. Malone and Gwynne discuss the challenges of living in a hybrid world between fee-for-service and value-based care, offer advice for providers seeking to join a CIN and explain how the organization keeps track of its intricate network of providers and contracts.

Editor's note: This interview has been edited for length and clarity.

Question: We are in a hybrid world between fee-for-service and value-based care. Can you describe some of the challenges associated with this reality?

Dr. Mark Gwynne: There are a series of challenges. First, value-based care holds the promise of delivering higher quality of care at a lower cost. This is forcing hospitals to look for sources of revenue outside of the fee-for-service contracts. It is difficult to find those alternative revenue streams until you scale significant populations under alternative payment models, which is fundamentally hard. On the physician side, it's very difficult to deliver equitable care across populations if patients are defined by payer. Essentially, the tools, infrastructure and provider behavior that results in value needs to cross all populations … which presents a challenge if only a small proportion of patients that providers see are in these alternative payment models. In addition, it is difficult to align provider incentives around small populations in value-based arrangements. There is also a barrier to providing good, actionable data to providers about small populations … With alternative payment models we have access to more significant information combining claims and clinical data. However compiling that data in a way that is digestible and meaningful for a provider network is a challenge when it describes just a small population. In an integrated delivery system, incentives also need to be aligned so that reducing unnecessary acute care is rewarded while hospital margins are not significantly affected. In summary, the levers, resources and investments needed to expertly manage populations and to really perform well in in value-based arrangements need to cross populations. To apply those resources in a limited fashion ends up being costly and challenging.

Dr. Robb Malone: Two things come to mind when I think about challenges.  First, I've heard people say that the shift to value is taking longer than they expected. I don't think that it is as slow or grinding as it may seem. We’ve needed this time to operationalize interventions, prepare providers for the change, align compensation, build care teams, and establish necessary analytics capabilities. Second, many ask, "when will we know that we've transitioned from the fee for service to the value-based care side?  Where is the tipping point?”  It's debated, but consensus seems to be that when 30 percent or more of your patients are involved in a value-based care arrangement, you can get the attention of providers and you will have the scale necessary to deliver one system of care for all. We know that providers don't want to work within a fragmented delivery system where one set of patients gets one care model, and another set of patients get something else. For UNC Health Care we aren't quite at that 30 percent tipping point yet, so some of the challenges are more fundamental and revolve around change management, ensuring providers that change is coming, and engaging them in decisions along the way.

Q: Physicians are in both volume-based contracts and value-based contracts. How does your organization track which providers are part of which contracts?

MG: A CIN is a safe harbor for various providers across the continuum to contract in alternative payment models. By definition, different contracts may have different providers or different networks associated with them. The landscape is becoming even more complex given contracts around narrow or exclusive networks. Those types of arrangements are very important for coordination of care and to align networks of high value providers around similar outcomes and similar goals. In exclusive network contracts providers need to be tightly aligned, especially if there is any effort or desire to jointly enter into risk-based arrangements. It is important and a challenge to identify those high value networks well and to identify patients that are aligned to providers in those networks. It is an important competency any integrated network must have.

RM: To make this work, payers and networks need to work together … Payers often use levers like narrow network plans... These plans require us to stand up an adequate network that is capable of delivering quality care to those patients.  This means access to care is a critical factor, requiring development of the medical neighborhood, delivering services that patients need close to home.

This means that a CIN must be able to identify who your providers are within a geography, know who is in network, who the preferred providers are, who delivers the highest quality care, and what services they deliver. It became important that we knew how to expose this information to referring providers with the goal of getting the right patient to the right provider at the right time, and within the patient’s narrow network benefit. To meet those expectations we knew that we needed to integrate key data to be successful, and we could not do so reliably on our own.  One key partner, Phynd, helped us develop a complete view of the providers in our market. This access and population health solution has been integrated into our technical and analytics workflows. It is how we maintain network and plan data and will be leveraged to support our narrow network needs.

MG: To summarize, developing a network and managing a high value network is a core strategy of a successful integrated network, and Phynd is a key technological solution to make that easier.

Q: What are some of the pros and cons of using technology, an outside partner to help keep track of provider contracts?

RM: Even though we've been investing in this space for the last several years, it is still relatively new for us. We have a limited number of value-based contracts under our belt. We don’t have a lot of history to base decisions upon.  We will have more contracts and direct experience in the next calendar year, so we will learn very quickly.   Likewise, the technology is new and still under development.  Best practice is developing for healthcare providers and vendors alike.

Q: How has establishing a CIN positively affected your health system?

MG: As an integrated delivery system, like almost any integrated system and particularly those based in academic medical centers, many silos of care have developed over time. While we have worked hard to coordinate care, those silos have the potential to prevent high-level coordinated care. One of our key focus areas as a CIN is to identify those silos, bridge care and improve coordination across the continuum. That includes bridging care gaps between ambulatory and acute care setting, through post-acute and even home-based care settings. Through our CIN, we have identified where we can coordinate care more effectively because our data offers a lens into the system. In addition, the Health Alliance has provided a platform to have broader conversations about improving quality and coordination across the continuum - our employed providers and entities now have a platform to work much more closely with our independent partners  throughout the region ... There wasn't a platform to do that well before.

The healthcare landscape is changing and changing very quickly. Our CIN has provided us the platform to enter value much more quickly, effectively and in a more coordinated way than we could have otherwise ...  and that means integration crosses multiple domains, including financial integration, data integration and clinical integration across providers and across geographies.

Q: What advice do you have for hospitals or providers seeking to join a CIN?

MG: It's interesting … There's aligning with the concept of value, which is wonderful. However aligning with the fundamental operational changes in how we deliver and coordinate care necessary to be successful in value is a different concept. If I were to give advice, I would say to look for a network that is aligned with your values, is positioned well to not only improve quality and  cost of care in the region, but also has the ability and depth of understanding of value-based contracting to partner with the right payers at the right time to be successful.

RM: You need to find a partner, someone you can trust.  The most successful networks and healthcare providers are going to be the ones that are in it for the long haul … A good partner will share a vision of obtaining the quadruple aim and have a shared understanding of what value means in practice.

I would also say that attitude is important. Don't bring a problem, bring a solution. If you're going to challenge someone with data that demonstrates need for improvement... Don't just give them bad news, offer solutions, resources, and interventions. People can't fix what they don't know and can’t see. So, get actionable data in their hands, offer solutions and good things will happen.  I believe that our network is built upon these principles of partnership and the quadruple aim. 

Find out more about the UNC Health Alliance here.

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