COVER STORY Cracking the Code By Mark Hagland


Health plan and provider leaders are learning how to leverage data and analytics for population health and clinical transformation


O


ne could grow old waiting for pre- dictions about the U.S. healthcare delivery and payment system to


come true; and indeed, many have. But one of the most important sets of pre- dictions is now at long last coming to fruition: as has been predicted for several decades now, the leaders of health plans, physician groups, and hospitals are fully collaborating together to leverage data and analytics to fuel robust population health management and care manage- ment efforts—and are achieving results. Just consider a few examples from around the country: • At the Indianapolis-based


Anthem,


Antonio Linares, M.D., regional vice presi- dent and medical director for Anthem National Accounts, notes that he and his colleagues have been focusing on the highest-utilizing plan members across the health plan’s western region, and sharing that data with their affiliated physicians. “Our analytics process can identify the 3 percent of their panel membership that are responsible for 29 percent of the panel’s healthcare costs. We’re able to give them that report, with actionable insights. The report can provide actionable insight around membership with poor diabetes compliance, asthma, or heart disease,” he says. “This lets the care provider focus additional efforts on these individuals you


need to address.” Using that data in one of the health plan’s western accountable care organizations (ACOs), he says, “We’ve been able to target members who have complex conditions and other situations, who need help and who would benefit from care coordination and disease man- agement programs at two times the level of accuracy,” and are now able to “create a future risk model that predicts 163 days in advance an individual who’s more likely to fall into one of those high-risk categories.” • Meanwhile, at L.A. Care, the contracted health plan for MediCal (the California term for Medicaid) enrollees in Los Ange- les County, Matthew Pirritano, Ph.D., director of population health analytics and quality improvement, reports that a program that he and his colleagues have created, called the “VIP Program,” has involved the development of “a regres- sion model that helps us to set targets for the number of encounters that our IPAs [independent practice associations—the normal form of physician organization in California] should be submitting to us.” Now in its fourth year, that program, which was in turn the more sophisticated version of an earlier pay-for-performance program, is helping Pirritano and his col- leagues to gauge “provider performance in a number of domains, like HEDIS and


6 hcinnovationgroup.com | NOVEMBER/DECEMBER 2019


member satisfaction, and also is attached to some other elements. There are action plans required from the IPAs based on the data we give them in their report cards,” he notes. “They see the data and if they’re low-performing on a measure, we require them to send us an action plan in at least one area. It’s been a very posi- tive program. We’ve seen improvements across the board in the performance of our network. The inspiration for it was looking at the variation in our network, and finding that there was considerable variation among high-performing and low-performing groups.” • An example of a partnership that is going even further is the joint venture announced on June 24 between Blue Cross and Blue Shield of Minnesota and the 900-physician North Memorial Health physician organization, both based in Minneapolis-St. Paul, which has made the organizations shared owners of the North Memorial Health clinics. Under that agreement, North Memorial Health’s 20 primary and specialty care clinics will operate as a joint venture overseen by the CEOs of the two organizations, Craig Samitt, M.D. of BCBSMN and J. Kevin Croston, CEO of North Memorial Health. “Healthcare costs too much, and it is too often difficult for people to understand and navigate. With this joint venture,


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28