Partnering with 23andMe for a Population Health Initiative

Renown Health’s recent partnership with 23andMe and the Desert Research Institute has been an astounding success. Just little over a month ago we announced the program which offered free personalized health and ancestry information to over 5,000 Northern Nevadans. We expected it would take two days to get that many people to sign up. You can imagine our surprise when the day after the launch of the event, all 5,000 slots has been filled up! So we decided to open up another 5,000 slots, which filled almost equally as fast.

Some reasons to which the success of this event could be owed would be the cost (it’s one hundred percent free for participants), the perks of genetic analysis (it’s something that many people are curious about, but would not think of paying for), and the simplicity of our system (all that is required is that participants show up, watch an informational video about the project, sign some forms, and spit into a tube). There’s also the additional incentive of knowing that those who participate are contributing to the overall benefit of the Nevada community.

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via Renown Health

Through our work with 23andMe, Renown Health now has access to over 10,000 samples of genetic analysis. By combining this data with our data on the medical histories of over 300,000 people, we will have a better overall picture of the health of those in Northern Nevada. The Desert Research Institute will draw even more insights out of this data by looking at it in conjunction with a number of social and environmental figures. The overall goal of all of this data-crunching is to figure out how different environmental, demographic, and environment factors interact. Once we have a better idea of this, we will be able to better allocate resources to those who need them most and may even be able to stop illness before it happens.

This data-gathering, data analysis, data sharing, and all around cross-organization collaboration truly epitomizes what population health can become. I’m very proud of everyone who has been involved in this initiative–from the participants, to the researchers, to the countless administrative workers who have made this possible. Additionally, this project would not be possible without the generous support of Governor Brian Sandoval and the rest of the government of Nevada.

I’m also taken aback at how warmly the community has received this project. For instance, KUNR gave Joe Grzymski of 23andMe a great interview and the Reno Gazette-Journal has provided us with some glowing press. We’re taking steps toward the future of medicine.

Mark Behl

MACRA: The Road Map to the Future of Healthcare

One date marked on the calendar of many individuals at the management level of health organizations is January 1, 2017. To some 2017 is being viewed as a “year of reckoning“.  Although this sounds ominous, most negative effects on health organizations can be easily avoided as long as providers are prepared for MACRA. Since 2015, MACRA has been slowly integrated into the operations of medial organizations across the country. In 2017, the performance of medical organizations that qualify as MIPS will be tracked and these results will determine how providers are paid in 2019.

This may sound a bit confusing. It sounds like money’s on the line. It sounds like big changes are coming. But what exactly does MACRA mean and what exactly is a MIPS? To answer these questions I’ve put together a brief starter guide to MACRA and what it means for the healthcare industry.

What is MACRA?

In a nutshell, MACRA is new set of rules and regulations that will reshape the way that medical organizations receive government funding, handle Medicare, and ultimately function. The government MACRA with bi-partisan support back in 2015. Given that MACRA is such a large overhaul of the healthcare system, adoption to the rules and regulations of MACRA has been generously spaced out over a timeline of many years.

 

MACRA Timeline

MACRA Timeline from eptechview.ttuhsc.edu

In brief, MACRA will change how Medicare pays medical providers.

Yes, but what does MACRA stand for?

MACRA stands for Medicare Acccess and CHIP Reauthorization Act of 2015.

And what does CHIP stand for?

Children’s Health Insurance Program. Basically the program that provides states with matching federal health insurance funds for families with children.

OK, so getting back to MACRA…

Yes, getting back to MACRA…

How will performance be tracked?

That depends. There are three different classifications of medical payment models: MIPS, APMs, and e-APMs.

More acronyms?

You bet. MIPS (or Merit Based Incentive Payment Systems) will effect the majority of providers. APMs (or Alternative Payment Models) are a bit trickier to qualify for. E-APMs (eligible alternative payment models) are basically a subset of APMs. APMs are still subject to MIPS, but will receive favorable scoring, with reimbursement rates that reflect accordingly.

Wait, Scoring?

Just like a building might need to reach certain benchmarks in order to be certified as LEED or an Olympic diver has to be mindful of technique and style in order to win a higher score from the judges, so will medical organizations need to meet certain benchmarks in order to receive more favorable payment rates.

That means that medical organizations will need to make sure they are reaching to achieve a slew of metrics pulled from PQRS (Physician Quality Reporting System), EHR (Electronic Health Record), and the VM (Value-Based Payment Modifier) outlined in MACRA’s performance measures.

MIPs from Impact-Advisors.com

MIPS model from Impact-Advisors.com

So what happens once all of these measures are taken into account?

Based on how an organization meets these metrics, they will be given a MIPS composite score that is either positive, negative or neutral. Each of these will adjust the base rate of a provider’s Medicare Part B Payment, which is money that an organization qualifies to receive from the government when a patient uses Medicare for services covered under Part B. And these incentives really do add up. Larger medical organizations stand to lose or gain 15 to 20 million bucks depending on whether or not they receive favorable scores.

So if hypothetically a lot of identical organizations are performing well, will they all get the same amount of money?

Not exactly. This system will be budget neutral.

Meaning?

That there’s a fixed pool of money available for medical organizations. Those with higher scores will in effect take away money from medical organizations that perform more poorly.

Sounds kind of harsh.

Admittedly, MACRA does pose some big challenges for the healthcare industry, but the overall goal is something that we could all agree on: better value and better outcomes for patients. The thing is, the healthcare industry is heading in that direction anyway. There are so many medical organizations out there right now that it’s less a matter of if someone can get to a healthcare provider, it’s which one should they go to. In order to stay in business, providers need to step up their game and really show patients that they value them.

So why is MACRA being introduced if we’re already seeing better patient-centered care?

At the moment government money is provided to healthcare organizations with much more lenient standards on the efficacy of care given. Basically, organizations that are continually doing a poor job of putting patient’s first are still being kept afloat by government money. MACRA will push these organizations to either improve or yield to nearby healthcare all-stars.

Sounds great, but I’m not interested.

Like it or not, MACRA is coming and all providers will need to adapt in order to stay afloat.

OK. So what should I do?

Learn all you can! One thing that is recommended is to see if your organization can qualify as a PCMH (Patient Care Medical Home). This will help getting qualified as APM a lot easier and also carries some rewards of its own. Renown Health was the 1st provider in Nevada and the 4th in the country to adopt the PCMH model.

 

Good luck!

 

Mark Behl

What Coffee and Population Health Have in Common

Coffee, refrigeration, the internet. One constant throughout history is that people often fear change. Specifically, people fear the advent of new technology.

A cup of coffee with a sugar cube and a pile of beans

I recently read a fantastic piece by Steven Overly in the Washington Post that explores just this concept. In brief, Overly boils down humanity’s hesitations into 8 conclusions:

  1. People sometimes oppose innovation even when it seems to be in their best interest.
  2. Technologies that are vastly superior to their predecessors, or don’t have any predecessors, are more easily adopted.
  3. Resistance to new technologies comes from three key constituents, including the average consumer.
  4. Humans make decisions about new innovations with their gut rather than evidence.
  5. People flock to technologies that make them more autonomous and mobile.
  6. People typically don’t fear new technology, they fear the loss it will bring.
  7. Technologists often don’t think about the impact their inventions have on society.
  8. Innovation is not slow, linear or incremental — but the government doesn’t realize that.

Looked at together, these reasons can be cited for the slow adoption of wider spread population health methods. Fortunately (like coffee, refrigeration, and the internet), we are starting to see these methods gain more and more favor.

 

Mark Behl

A Population Health Crash Course

The field of “population health” is one of the most exciting developments in healthcare in the last last 15 odd years. However, actually describing what population health is can be a little tricky. Although I’ve broken it down before in other blog posts, I thought I’d compile some videos that make the meaning of population health a bit more accessible:

For starters, here’s a general overview:

So, you might be thinking, “That sounds a lot like public health.” Here’s the difference:

 

A great video that looks at the social determinants that are so critical to consider in the population health paradigm:

Thanks for viewing.

For more population health updates, follow me on Twitter @MarkBehl.

Confronting Zika with a Population Health Paradigm

With the arrival of the Zika virus in the United States, the nation and its medical organizations are mobilizing to prevent its spread. Integral to this process is sound population health practices.

Seemingly Innocuous

image of a mosquito on skin

Meet Aedes Aegypti, the main courier of Zika / WHO

If you haven’t heard, the Zika virus is one of the biggest infectious diseases to roll into the states since the likes of West Nile and H1N1. Although the disease can be sexually transmitted, what’s more troubling is that it is known to spread via Aedes aegypti mosquitoes.

At first glance, Zika doesn’t seem like that threatening of a harbinger. The initial symptoms of the virus are for all intents and purposes relatively innocuous: headache, muscle pain, fever, rash, conjunctivitis. In fact the symptoms are so mild that in many cases those infected with Zika are completely unaware of it. The thing is: it’s not those who are infected that are at risk. It’s their offspring.

Zika is known to cause birth defects such as microcephaly, in the children of mother’s who’ve conducted the virus. The danger is not just for our generation, it’s for future ones.

Not Enough Funds

The United States government recently started putting funds towards combatting Zika. President Obama initially asked for $1.9 billion to combat the disease. The House of Representatives instead opted for a bill that wold send a meager $622 million, most of which is currently going to other Health Department like programs like those that are confronting ebola. The Senate’s package on the other hand proposes $1.1 billion, which will not only give the Health Department ample funds to educate and prepare Americans, but also will give the CDC the amount of funds they’re asking for research–research that includes the discovery of a vaccine.

image of Dr. Frieden speaking at Senate.

Dr. Frieden urging the Senate to approve more funding to combat Zika. (AP Photo/Manuel Balce Ceneta)

Today Dr. Tom Frieden of the CDC urged the nation’s officials to act and act soon: “We have a narrow window of opportunity to scale up effective Zika prevention measures, and that window of opportunity is closing.” But with the House and Senate empty during Memorial Day weekend holiday, the unofficial start of mosquito season, it looks like any action is to be delayed.

Population Health in Action

For instance, in New York, Governor Andrew Cuomo has initiated a state-wide initiative to prepare for Zika. In addition to aggressively pursuing methods of staving off Zika by deploying mosquito traps and staying vigilant for any outbreaks, the state has put forth a number of initiatives that directly assist residents. Such as issuing Zika protection kits to pregnant women who recently traveled or lived outside the country.

Of course the strength of population oriented health program is not just in having the care-providing agency (in this case government) provide aid itself; it’s in training individuals to be Zika-fighting agents on their own. In New York this is being seen in efforts that educate residents to reduce standing water, use larvicide tablets where standing water does exist, and assiduously utilize mosquito deterrents such as mosquito repellant. Most importantly, the state is asking residents to point out large outbreaks of mosquitos. Granted, it might be hard for the average person to figure out what a large outbreak is, in comparison to an average outbreak. But by putting out feelers, by activating more individuals to report data, the state is enacting the fundamentals of an effective population health campaign.

New York is not alone in gearing up for the arrival of Zika. Bringing further aid, the CDC has made it possible for states and province to apply for additional funding to combat Zika locally.

Micro to Macro

At the core of modern population health practices is the triple aim:

  • Increasing the prevalence of evidence-based, preventive health services and behaviors
  • Improving care quality and patient safety
  • Advancing care coordination across the health care continuum

It doesn’t take that much of any eye-squinting to see how the fundamentals of the triple aim can been seen in the government’s mobilization against Zika.

  • Increasing the prevalence of evidence-based, preventive health services and behaviors

By educating people on the risks of Zika and empowering them with the means to prevent it, the government is using the research at their disposal (evidence-based knowledge) to spread preventive health services and behaviors.

  • Improving care quality and patient safety

The more that the government learns about Zika, the more empowered it is to combat it–one of the reasons why additional funding for government agencies is so important. The ultimate boon here being a vaccine.

  • Advancing care coordination across the health care continuum

Similarly to the first aim, this includes empowering citizens to take on Zika themselves. However that this just one point on the healthcare continuum. Under the the larger government’s guidance, we are seeing individual government agencies (like the CDC) collaborate, in addition to a number of private sector organizations (including Gilead Sciences Inc., Inovio Pharmaceuticals Inc., and Intrexon Corp. With the government’s oversight, these organizations are acting less in silo, and more as individual fingers of the same hand.

an infograph depicting what people should to protect themselves from ZIka

An example of the sort of materials being circulated by government agencies, in this case the CDC, in order to educate.

As idea of population health grows in popularity, we’re seeing more and more hospitals take health to the people. It’s not just enough to wait and see who comes. It’s a matter of going into the community. It’s about seeking an integrated, holistic and widespread approach.

Mark Behl

Mentrics: Redefining the Possibilities of Population Health

IBM Watson is one of the most exciting developments in population heath. It has an unprecedented capability for processing high volumes of data and turning that data into natural language answers. IBM Watson is like Siri on steroids. Through partnering with a number of organizations, IBM has been able to increase the range and power of the Watson. One of the most recent partnerships in this direction has been its partnership with ODH Inc. The progeny of this collaboration is called Mentrics.

Mentrics gives Managed Care Organizations (MCOs) and Behavioral Health Organizations (BHOs) like Renown Health the ability to “understand the whole population, segment the population needing intervention AND manage and monitor the key determinants of health for each segment.” Not only will Mentrics give population health organizations more data to work with, it will make providing healthcare cheaper and more streamlined–specifically when targeting those segments that suffer from a chronic comorbidity.

The Cost of Comorbidity

When patients have a physical and a comorbid (coinciding) mental health disorder, treatment becomes more costly and often less effective. For instance, a patient with diabetes and depression has a 200% higher mortality patient compared to a patient who only has diabetes. Furthermore, individuals with coronary artery disease and depression are 2 to 3 times more likely to incur a future cardiac event. Those who fall into this segment of comorbidity of chronic physical and mental health cost 300% more than those with only only chronic health condition.

Bottom line: the greatest healthcare expenditures are going to a small group. We need a way of addressing this specific group. Big data, population health, and specifically Mentrics is the answer.

image of mentrics logo

Mentrics in Action

HITConsultant.com has identified three specific areas in behavioral health that Mentrics will benefit

1) Behavioral Health Population Management

Using 22 dimensions including a model for behavioral health specific risk stratification (the only commercially-available one on the market thanks to IBM Watson), Mentrics will be able to create clinically meaninful poplulation segments.

Bottom line:  This will help medical professionals to identify which segments will most likely benefit from interaction.

2) Provider Network Performance

With Mentrics, providers will be able to assess their own effectiveness and efficiency, allowing for a comprehensive comparing of providers and an analysis of the entire provider network. This will in turn work towards value-based payment arrangements.

Bottom line: Money will be allocated more accurately, efficiently, and economically.

3) Patient Care Coordination

Using a user-friendly, “Longitudinal Data Visualization tool”, cross-network providers will be able to notice detailed patterns in medication use and clinical history. Furthermore, providers will be able to receive notifications based on evidence-based care gaps like patients receiving duplicate prescriptions and providers will be able to customize cross-network care via these notifications.

Bottom line: Providers will have a more holistic view of patients and will have an interoperable system in place for communicating with other providers.

Realizing the Vision of Population Health

Years ago, population health was a vague though ambitious field. It promised an integrated cross-network system that optimized patient outcome and reduced patient cost. Yet, it seemed that there was no shortage of hurdles blocking population health from ever realizing its vision.

But recent developments in digital health, such as Mentrics prove that there is indeed hope for an ubiquitous population health model. Mentrics provides providers with unprecedented awareness of the millions of variables that go into a healthcare system. Now it’s just a matter of this brilliant software finding its way into practice.

How Apps and Wearables are Changing the Population Health Landscape

At the center of modern population health practices is data. Traditional forms of gathering data include culling medical records, analyzing ever scrap of demographic information available, looking at medical studies conducted, and gleaning information from other people/systems/organizations that are compiling their own health databases. But the advent of smartphones and wearable apps allows a whole new sort of data collection. It allows access to real-time, uniquely tailored data for an individual, and at the same time (when enough individuals are using the app, mobile apps and wearables) allow access to lots and lots of numbers. Numbers that can change the landscape of population health for a community and for the world.

Health Apps

Image of intellicare apps

Northwestern’s Intellicare app suite opens a new door into quickly and easily collecting data on mental health.

From Apple’s Healthkit to Samsung’s SHealth, apps that help people measure their fitness activity and diet are becoming more and more popular. But we’re also seeing the emergence of a level of unprecedented apps, such as Northwestern University’s Intellicare  app suite that focuses on mental health. Using a variety of approaches to treating mental health based on Cognitive Behavioral Therapy (CBT), the Intellicare suite holds the potential to provide data on mental health from a variety of patients. Although not a complete substitute for face-to-face interaction, the app suite grants patients an accessible and cheap first line of defense resource. Yet another a tool in the value-based healthcare model.

Wearables

image of a fitbit

Wearables adoption is set to double from from 2014 to 2019.

A recent study in 2015 indicates that patients with multiple sclerosis were much more likely to engage in an activity tracking physical fitness with wearables. Over 24o patients enrolled in the study to track their activity with Fitbits and 77% made it all the way through to the post-study follow-up survey. For starters, wearables are cool. Just like it’s fashionable to have a smart phone, it’s fashionable to have a Fitbit. According to a survey conducted by RBC in 2015, Fitbits are one of the most in-demand wearables out there.

And the wearable market is only going to grow. The investment firm Piper Jaffray expects that from 2014 to 2019, wearable technologies are expected to nearly double in adoption across the world. They point out three trends behind the widespread growth of wearables (which could be attributed to health apps as well):

  1. Health and fitness becoming a growing concern among individuals in more and more demographics
  2. People wanting to be able to quantify and analyze more and more of their activity
  3. Convergence between brands and tech e.g. UnderArmor acquring MyFitnessPal, etc.

Privacy Concerns

As more and more consumers use apps and wearables, more data becomes available. But as the availability of data grows, health organizations and other businesses need to make sure that they are harvesting this data in ethical fashion. There have already been several law suits in regards to companies not being upfront about their privacy policy. Moving forward, companies need to work with consumers’ full awareness and trust if they are to make the most out of the data available.

What are your thoughts on apps and wearables? Is there a particular company or product that you think is making strides? Let me know @MarkBehl.

Population Health Platforms

The purpose of population health management is manifold: it helps improve the the health outcomes of people by improving the quality of care, increases preventive care, and provides access to better care. The golden promise is that healthcare providers will be able to deliver better care at a lower price. In order for this to happen, caregivers at all sides of a patient need to be interconnected with a digital framework.

As mentioned in another blog post, this past year has been a booming time for digital health companies that harness population health. There are a number of ways that digital health companies can approach population health. Below is a breakdown of the platforms that make up population health management as detailed by Miguel McInnis, the founder of McInnis & Associates, a healthcare management and consulting firm. As with any attempt at categorization, there is some overlap.

NueMd mark behl

Population health intelligence platforms can provide plan administrators and care teams with cloud-stored access to extensive financial and clinical information, and access clinical data from a number of sources. They may also link to other population health platforms like risk stratification, hospital admission data, and referral data. Example: Conifer Health Intelligence

Medical Management systems combine people and information to effective and personalized services for acute care management, chronic care management, etc. These systems use accurately integrated data to identify at-risk patients, track results, analyze care and support wellness management. Example: NueMD

Risk Stratification tools identify different population needs across all levels of risk. WIth this info, providers can determine appropriate courses of action with which to approach the needs of a population. Of prime importance here are demographics, medical conditions, cre patterns and resource utilization. From here, patients can be stratified into five main categories: episode of care patients; high risk patients; chronically ill patients; healthy patients but with conditions; and healthy patients. Example: HExL

Patient Engagement services AthenaHealth mark behlhelp help patients take part in their own healthcare. The goal here is to help create a supportive, long-term relationship with a patient using third-party data to figure out the needs of patients and facilitate more effective relationships with providers. Example: AthenaHealth

Predictive Analytics tools model medical conditions within a population to identify high people who may be risk. By identifying these patients ahead of the curve, predictive analytics can prevent these people from needing to shell out for expensive healthcare. Example: Evolent Health

Better Patient Access platforms help patients interact with providers. This is especially useful when patients have poor access to healthcare. One way of doing this is with telehealth which ties together some of the above platforms in order to provide not only better care to patients, but also better training to providers. Example: Doctor on Demand

 

For the full article, check out Forbes.com.

 

Getting the Bigger Picture in Population Health

When it comes to ensuring the healthcare of an individual, leveraging data is helpful. But when we it comes to addressing the healthcare of whole communities that can range from a hundred to several billion people, harnessing every ounce of data is down-right essential. Still, the integration of data in population health still faces a number of hurdles. A recent article from Health Data Management touches upon some of the challenges. In this post, I extract and further explain this challenges and illustrate how they might be overcome.

explorys

Explorys.

Not all of the data needed for clients can be gathered from a quick office visit or simply by perusing a database. There are a lot of gaps in current databases and so the challenge there is in 1) determining what those gaps are and 2) addressing them.

For instance, determinants like access to clean water, access to good food, access to a gym, reliable climate control, and even whether or not someone has the right clothing to keep them warm enough when walking about town during winter are all factors that need to be considered. If a client doesn’t have access to any of the above, that will have an effect on the likelihood of them being admitted and/or readmitted to a hospital. Getting data in these fields will help providers increase the overall well-being of their patients by looking at care as something that transcends the hospital/clinic/office.

One example of a company that is looking to overcome this gap is Exlplorys. Working with 23 health systems that represent about 360 hospitals, Explorys’ database contains claims and clinical data on 55 million patients, which can in turn be utilized by clients to organize patient populations by risk.

evolvent health logo

Evolvent Health

Another company that is doing great work is Evolvent. Starting with work at the University of Pittsburgh Medical Center, Evolvent now helps organize analytics for almost a million patients in 25 markets.

Companies like Explorys and Evolvent incorporate data from a variety of sources, including air quality data, census data, and real estate information, drivers’ license data, and credit scores. Indeed, the sky is (almost) the limit when it comes to where data is pulled from.

Population healthcare is about leveraging data to provide the best healthcare possible. To ensure that providers are providing the best healthcare possible, it would seem that no rock of data should be left unturned. Yet, as mentioned in a previous post, it’s not just a matter of gathering data–it’s about gathering relevant data.

I’ve already managed the Health Management News article above. But for more great information on this topic, check out Forbes.com.

 

Moving Toward Population Health

 

As hospitals adapt to value-based payments and delivery models, they are figuring ways to evolve their business models and extend services beyond their four walls.

With the shift from volume- to value-based payment and care delivery models, hospitals and care systems are exploring different paths for organizational transformation to achieve Triple Aim outcomes — better care, better health and lower costs. This involves going beyond the hospital’s traditional role — efforts that are focused on caring and personalizing services for individuals admitted to the hospital — and providing services outside the facility’s four walls to more proactively engage patients and communities.

Achieving Triple Aim outcomes

Population health management is one upstream intervention that can achieve Triple Aim outcomes in a value-based environment. It involves integrating preventive principles into care delivery to improve the health of a defined population. Key elements of population health management include identifying health determinants and addressing modifiable factors, promoting health and wellness, and implementing disease prevention and management programs.

Two AHA guides, “Managing Population Health: The Role of the Hospital” and “The Role of Small and Rural Hospitals and Care Systems in Effective Population Health Partnerships,” outline how population health serves as a strategic platform to improve health outcomes. These guides explain how population health resides at the intersection of three distinct mechanisms:

  • Increasing the prevalence of evidence-based, preventive health services and behaviors
  • Improving care quality and patient safety
  • Advancing care coordination across the health care continuum

Population health in a value-based environment

In a volume-based environment, hospitals and care systems implement small-scale, disease-specific programs. As the health care field moves toward more value-based payment approaches, organizations will need to create major systemic and cultural shifts to implement population health management.

Successful population health management programs align mission with services that support a defined population and leverage internal and external resources to address community needs. Hospitals and care systems that successfully developed a sustainable population health management program have fee-for-value contracts that incentivize programs to achieve population health goals. Many health care organizations already are going beyond traditional partnerships and collaborating with community organizations, payers and other clinical care sites to address health care issues.

The second curve of population health

A new Hospitals in Pursuit of Excellence guide, “The Second Curve of Population Health,” highlights six tactical areas that advance population health management in hospitals and care systems:

  • Value-based reimbursement
  • Seamless care across all settings
  • Proactive and systematic patient education
  • Workplace competencies and education on population health
  • Integrated, comprehensive HIT that supports risk stratification of patients with real-time accessibility
  • Mature community partnerships to collaborate on community-based solutions

The guide provides metrics for evaluating population health initiatives and includes several hospital case studies.

Rhoby Tio, M.P.P.A., is a former program manager for the Health Research & Educational Trust. To access “The Second Curve of Population Health” and other resources on population health management, go to www.hpoe.org.