New Payer-provider Five-year Contract Pushes the Envelope on Care Coordination
Health system agrees to guarantee
EXECUTIVE SUMMARY
Independence Blue Cross and the University of Pennsylvania Health System signed a five-year contract, effective July 1, 2017, to share accountability for quality and cost.
- Independence spends $1.2 billion annually at University of Pennsylvania Health System facilities.
- UPHS has agreed to provide Independence members with a 30-day readmission guarantee on all inpatient services and surgeries.
- Case management and care continuum services are expected to be a part of the change.
Even as changes to a national healthcare framework have occupied public debate in 2017, there’s evidence that the trend toward care continuity and keeping patients out of the hospital are here to stay. A new, five-year contract between two powerhouses in the healthcare arena suggests that the era of fee-for-service medical care will continue to evolve into a fee-for-value model.
Independence Blue Cross and the University of Pennsylvania Health System (UPHS) signed a contract, effective July 1, 2017, which will give the organizations shared accountability for quality and cost of care. UPHS has joined the Independence Facilitated Health Networks (FHN) model, which focuses on better care coordination.
The agreement is huge, as Independence spends $1.2 billion annually at University of Pennsylvania Health System facilities, says Anthony V. Coletta, MD, MBA, president of Facilitated Health Networks, Independence Blue Cross of Philadelphia.
“It’s a big system with a huge number of patients,” Coletta says. “We spend in the Philadelphia market $6.5 billion in healthcare every year, and Penn is a big piece of that.”
With a large customer population, there’s a need to lower costs and create a more efficient workforce, he notes.
The Facilitated Health Network model works to achieve this goal through its three pillars, including engage, enable, and empower, Coletta says. “‘Engage’ is economic — decreases the rates and puts in new value-based programs,” he adds.
One example of this is the Independence-UPHS contract’s focus on shared accountability. In the agreement, UPHS will provide Independence members with a 30-day readmission guarantee on all inpatient services and surgeries.
What this means is that any time an Independence member is readmitted to a UPHS hospital within 30 days, the health system will cover their costs. “There is no cost to members or Independence,” Coletta says.
“We consider this to be a bold statement that indicates they’re stepping up to be increasingly accountable for both quality and cost,” he adds. “It’s the first [30-day readmission guarantee] in Philadelphia, and I suspect it’s one of the first in the country.”
The pillar of “enable” relates to data exchange. The new contract between Independence and UPHS will include a robust data exchange and care management platforms. Clinical data will be merged with claims data, Coletta says.
Data exchange makes it possible to perform risk stratification of health populations and manage them collaboratively. The data is in real time, enabling physicians to make better-informed decisions.
Data will include specialist and facility utilization, drug prescribing patterns, and potentially preventable ED visits.
“It allows you to identify the patients who have the most complicated needs on the care management side, and you can aggregate the claims to demonstrate who has the most chronic conditions,” he explains.
The empowerment piece relates to enhanced, coordinated care management between the two organizations’ care teams. An Independence clinical care transformation team will work with UPHS doctors. They’ll help to manage cost efficiency by sharing reports that compare cost ranking from low to middle to high for frequently performed procedures.
Also, there will be care groups that include staff from both organizations to meet quarterly to share best practices.
“So instead of us being siloed, we’ll increasingly engage the health system to get as close to a point of care in a coordinated way,” Coletta explains.
For instance, each hospital has case managers working with Independence teams to find patients the right skilled nursing facility, where they can complete rehabilitation successfully and return home, he says.
“There are nurse navigators, who are care managers, out in practices, seeing these complicated patients when they’re seeing their doctors, and establishing care management plans for these patients and helping them to implement those plans,” Coletta says.
Another strategy involves enrolling the highest-risk patients in a house call program.
“We deploy people to their homes,” Coletta says.
The house call program involves sending clinical practitioners to Independence members’ homes. “There’s a core group of clinicians: RNs, nurse practitioners, and physicians, supported by behavioral health social workers, and — we anticipate with the Penn agreement — community health workers, trained beyond a high school diploma, but not with a clinical degree,” he says.
Ideally, the first encounter would involve a nurse case manager who assesses the patient’s case and establishes a care plan, Coletta says.
The house call program is resource-intensive, but it can identify social determinants of health obstacles that otherwise would be difficult to spot.
For example, Coletta accompanied a non-Independence physician to a couple of Independence members’ homes and found the experience to be fascinating.
They first visited a man who had congestive heart failure (CHF). He had several follow-up needs, including medication reconciliation and an appointment with a cardiologist. But he also was experiencing an exacerbation of his CHF.
“It was an hour-long visit, and most of what she did was what a doctor would need to do,” Coletta says. “The other half could be done by a nurse care manager.”
At the second visit, Coletta and the physician saw an elderly woman who had chronic obstructive pulmonary disease (COPD), and lived alone. That visit took two hours.
“I sat and watched for an hour, seeing things that could have been done ahead of time,” Coletta says. “The model is growing and scaling up, and it’s very engaging to see that level of intensity in the home.”
The patient lived in a home with very steep steps. She had a long oxygen tank, and she walked slowly up the stairs, trailing the tank’s hoses between her legs. She was an apparent risk for falling and injuring herself, he says.
“She had six empty oxygen tanks in the corner, and she had mistaken her daily inhaler for her emergency inhaler and was confused, not taking her inhaler in the way it was prescribed,” Coletta says. “This is emblematic of how critical these cases are.”
The experience also reinforced the importance of having home visits. Seeing how the patient struggled with her oxygen tank on the stairs could lead to a physician or case manager suggesting a solution that would reduce her risk of falling. The physician was able to get the patient back on her maintenance inhaler, taking it correctly, which could prevent an ED visit.
“You have to deal with their social determinants, and — to me — the imperative is to figure out a way to scale that model up, linking the hospital work to the rehab facilities where they’re often discharged, and from there to their homes,” Coletta says. “Inside the engagement model, you invest in resources to keep people out of the hospital.”
Independence Blue Cross and the University of Pennsylvania Health System signed a five-year contract, effective July 1, 2017, to share accountability for quality and cost.
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