The Hot Spotters Sequel: Population Health Heroes

Dave Chase, Contributor

CEO of Avado: Powering the disruptive innovators reinventing healthcare

Frail elderly and polychronic patients are a special challenge for our healthcare system. Many have tried and failed to get these two tough cohorts of patients on track to better health. Atul Gawande’s refers to them in his New Yorker piece as The Hot Spotters. Just as law enforcement in community policing identifies crime hotspots, the most challenging (and expensive) patients in a community are identified and become a part of a model that is very proactive about reaching out to them.

The primary focus of Gawande’s article was on a program put in place in Camden, New Jersey by Dr. Jeff Brenner that has received much acclaim. Dr. Brenner has justifiably been lauded for his work and is on the speaking circuit. Less noticed was another physician featured in that article — Dr. Rushika Fernandopulle — who has gone on to aggressively expand on the model that was written about. Dr. Fernandopulle is one of the examples of DIY Health Reform that is providing guideposts to government-driven health reform.

I’ll highlight a few examples of DIY Health Reform that kicked in before Obamacare, yet provide a road-map to programs such as a major program in New York that are building off of these DIY Health Reform approaches. To the extent that the evolving landscape follows models such as the pioneers outlined here, I’m optimistic about the future of healthcare. On the other hand, if Medicare squashes proven models, we’ll be doomed to a continuation of a healthcare system not realizing its full potential. Each of the examples here stand in stark contrast to the common problems outlined in the recent Kaiser Health News/Washington Post article Health Care’s ‘Dirty Little Secret’: No One May Be Coordinating Care.

I have outlined three overarching themes followed by a few examples of providers who have adopted a Hot Spotters type model. Kaiser Permanente is often held up as the future of healthcare in the U.S.  However, I would argue that the models pioneered by Iora Health, the Nuka Model, CareMore, and the New York Health Home program offer a more replicable set of models. Read on for more on each program.

Overarching Theme # 1: Population Health Management
Population Health Management (PHM) has been defined as “the technical field of endeavor which utilizes a variety of individual, organizational and cultural interventions to help improve the morbidity patterns (i.e., the illness and injury burden) and the health care use behavior of defined populations.” Though they take different approaches, they all recognize that the most important medical instrument is communications – something that is woefully under-prioritized in our expensive and inefficient healthcare system.

Brenner describes it vividly. “There is a bias in medicine against talking to people and for cutting, scanning and chopping into them. If this was a pill or or a machine with these results it would be front-page news in the Wall Street Journal. If we could get these results for your grandmother, you’d say, ‘Of course I want that.’ But then you’d say, what are the risks? Does she need to have chemotherapy? Does she need to be put in a scanner? Is it a surgery? And you’d say, no, you just have to have a nurse come visit her every week.” In other words, yet again, patient engagement is the blockbuster “drug” of the century.

A recent past president of the American Academy of Family Physicians, Dr. Ted Epperly, described to me the failing of our present model during a tour through his clinic (disclosure: Dr. Epperly is an advisor to my patient relationship management software company). We stopped at the waiting room in one of the clinics he runs and he simply stated “this is a failure.” When I asked why, he described how they were essentially sitting there waiting for patients to present themselves. Instead, he outlined a vision of a dashboard that proactively manages which patients should be seen if they haven’t heard from them and one that is tracking other patients looking for signals where they should intervene before some issue flares up. The metaphor is less catcher’s mitt and more NASA control center (astronauts were, after all, the original Quantified Self crowd).

Last week, as part of the Oliver Wyman Health Innovation Center advisory board (see Healthcare’s Trillion Dollar Disruption for more), we had a half-day site visit to one of the most successful Medicare Advantage programs in the country (read about CareMore below). Core to their PHM approach is they state that primary care should be an outbound activity, not an inbound activity.

Overarching Theme # 2: Primary Care isn’t Milk in the Back of the Store

As Leeba Lessin (CareMore President) stated ”Primary care has become a specialty referring mechanism, not care driven.” Said differently, our flawed reimbursement model has effectively turned primary care physicians (PCP) into “milk in the back of the store” — i.e., a low margin service intended to direct people to high margin products/services. If a PCP can only make a good living by averaging 7-minute visits with patients, there is little choice but to rapidly figure out whether the presenting symptom is best addressed by a pill, test, or procedure. It’s no wonder that the most unsatisfied physicians are PCPs operating in that broken model. In contrast, the most satisfied physicians I know are operating in one of the models described below that get them off of the 7-minute-per-patient hamster wheel.

All of the models outlined below have rethought their primary care focused models from the ground up. Dr. Fernandopulle stated “What everyone else is trying to do is improve existing practices, making incremental improvements. We figured out that maybe what we need to do is start from scratch.” In one conversation we had, he put it more colorfully as “others are putting wings on cars and calling them airplanes” when I asked him about a popular new model called patient centered medical homes (PCMH). While he agreed with many of the PCMH principles, he believed that simply layering on some new payment structure on top of a severely flawed model was doomed to under-perform.

Team-based primary care is central. For example, Maimonides Medical Center is a pioneer in New York running the “Health Home” program for Brooklyn. [Disclosure: Maimonides Medical Center is a customer of my patient relationship management software company.]  In New York, the Department of Health led by Dr. Nirav Shah is deploying a Health Home program Maimonides is helping to pioneer. The Health Home program has many care team members coordinating care that contrasts sharply with the uncoordinated model of care that is a defining element of today’s healthcare system.

Overarching Theme # 3: Highly Patient-centric Providers

Despite far outperforming their peers, the health organizations highlighted here are tough on themselves. When asked how they’d improve, their comments universally mapped to addressing The 7 Habits of Highly Patient Centric Providers listed below (follow link for more detail on each of the habits).

1. Multi-provider patient portal/tools
2. Medical information is made relevant
3. Patient-generated data is sought out
4. Portable and on the patient’s terms
5. Collaborative care process with shared decision making tools
6. Patient-facing tools that are inviting to use
7. Recognize the importance of caregivers and the Family proxy

While they are far ahead of their competition, even the organizations outlined here don’t have all of these items. They all recognize that in order to maintain their leadership, they will relentlessly improve in these areas.

Unfortunately, stating one is “patient-centric” has become an overused and abused term. Here is how the leader’s of the Nuka Model described what they do in Family Practice Management (PDF) in contrast to the platitudinal use of “patient-centric.”

There’s a lot of talk about being “patient-centered.” Unfortunately what that usually means is that the patient is put in the middle and then all “really smart professional people” stand around and try to decide what’s best for that person.

In the Nuka model, they use “customer-driven”. This means that everything the customer-owner defines as needs, goals and values become the system’s focus. The doctor and clinical team provide expertise, keep track of preventive matters, explain options and make recommendations. But the customer-owner is in control and makes decisions, rather than the providers trying to decide what is best.

It turns out that when given this kind of control and partnership over time, customers make knowledgeable, informed decisions about their health care treatment and generally choose less aggressive treatments than medical professionals would choose for them.

For the Nuka Model and the programs outlined below, being “patient-centric” isn’t a market platitude — it’s a central design point of their programs and technology. In all of the examples below, the most important enabling software was homegrown or came from a startup. Naturally, the incumbent vendors are profiting and optimizing from the old models. Like any market shift, newer vendors have an advantage as they can nimbly address the nascent market segments that aren’t big enough to get the full focus of the incumbent vendors. Rather than simplistic and silo’ed patient portals that are merely a marketing checkbox, as leading healthIT thinker Shahid Shah has stated, “sophisticated patient relationship management software is the #1 requirement of new accountable models.”

Example # 1: Medicare Advantage Program Wildly Outperforming Its Peers
If you want to get both excited and depressed at the same time, study CareMore. It’s exciting that they have achieved such impressive results within a federally-funded program (Medicare Advantage). On the other hand, it’s somewhat depressing that it hasn’t expanded faster and doesn’t have greater market presence. While it’s a great validation that Wellpoint acquired CareMore for $800 million, it doesn’t appear Wellpoint has done much to embrace and aggressively expand upon this successful model beyond the organic growth CareMore leaders continue to drive.

Oliver Wyman’s head of their Health Innovation Center, Tom Main, co-wrote a piece outlining CareMore’s success entitled The Quiet Health-Care Revolution for The Atlantic. Take a moment to read it. As you’ll see, CareMore is dramatically outperforming their peers with much better health outcomes, lowered costs, and highly satisfied patients. During the site visit, I took notes on what stood out. Here’s a summary:

• Early intervention is central to their model. CareMore has proprietary resources and predictive modeling allowing for early intervention to prevent acute episodes. See The Atlantic article for an example of how they repeatedly save 98% off of what is typically spent for a common scenario. They’ve learned that many patients fare better with less complex healthcare interventions.
• At every turn, CareMore challenges the status quo. In their experience, they believe 50% of healthcare costs for chronically ill can be avoided. Though they were founded by a physician they state “A high percentage of physician services can be delivered by non-physicians.”
• They believe prepayment (capitation) is freedom, not risk.
• In their experience, a patient can go from being in the Easy chair to ICU in 12 hours so they must rapidly intervene. They talk about “Speedy Delivery” — i.e., services and programs that can be delivered within minutes.
• CareMore has a “Longitudinal Patient Record” that collects information from several sources — the EHR is only one of 8-10 sources. See Health Systems Spending Billions to Prepare for the “Last Battle” for a contrast with what typical organizations are doing. CareMore’s Longitudinal Patient Record approach is the future. A silo’ed EHR is the past. While I prefer the term Collaborative Health Record to Longitudinal Patient Record, CareMore’s approach is visionary.
• CareMore states that “Education is a large part of what a patient needs.” See Khan Academy Approach Poised to Solve a “Wicked Problem” in Healthcare for more on one approach to addressing this issue (besides face-to-face encounters).

Example # 2: Direct Primary Care: Secret Weapon Hidden in Obamacare
The simplest way to explain Direct Primary Care (DPC) is “concierge medicine for the masses.” Because it’s a small portion of the Obamacare bill and it has bipartisan support, I’ve called DPC the “David Clause” in Obamacare Ready to Slay the Healthcare Cost Beast. Recognizing its significance, the California Health Care Foundation commissioned a paper to be written about DPC. As they did several years ago when retail clinics emerged, the CHCF analyzes emerging trends on the cusp of high growth.  The release of the paper couldn’t be more timely as the biggest obstacle to DPC exploding more broadly has been the lack of a national insurance player getting behind it — that will change in the next month. On a related note, a regional Blue Shield recently invested in the pioneer of DPC, Qliance. It’s not hard to imagine that they’ll also develop a DPC wraparound policy.

The other obstacle to DPC gaining a big footprint is a national player on the provider side getting behind it. The closest so far is DaVita’s Paladina Health division. With DaVita’s national footprint with their dialysis clinics and their recent $4.4 billion purchase of HealthCare Partners, it’s clear they have their sites set on something larger. It is only a matter of time before a national player that has retail and/or onsite clinics such as Walgreen’s or Walmart will partner with a national insurance carrier. It’s notable that the national insurance carrier isn’t a traditional health insurer. In other words, they have nothing to lose.

Contact me via LinkedIn at http://www.linkedin.com/in/chasedave if you’d like a copy of the seminal study of Direct Primary Care

Perhaps the best demonstration of applying the hot spotting approach in DPC is Iora Health (click link for a previous profile with a slideshow of their outcomes). Dr. Fernandopulle founded Iora Health which just received another round of funding bringing its total to over $20 million raised including funding from Zappos founder, Tony Hsieh. We now have Tony Hsieh, Jeff Bezos, Michael Dell, and Rich Barton (Expedia & Zillow founder) having backed DPC practices.

Two concerns have been raised about DPC. Most recently, I was speaking with Tom Main, the head of Oliver Wyman’s Health Innovation Center who raised these same concerns.

1. The movement towards DPC could exacerbate the shortage of primary care physicians. As I outlined in WSJ Underestimates the Power of the Market and Healthcare Entrepreneurs, our flawed healthcare reimbursement system has done a masterful job of making primary care increasingly a miserable existence. The most unsatisfied physicians I meet are in fee-for-service-based primary care. In contrast, the most satisfied physicians (of any kind) are those in DPC models. The comment of one who had made the shift was striking when I asked him why he opened a DPC practice. He stated that he found that in order to meet his “productivity” requirements, he was only using 40% of his medical training and felt that it was borderline unethical to continue practicing in a fee-for-service model. While it is true DPC practices have smaller patient panels (typically 500-1000 patients), so do the Extensivists (intensive primary care) in models such as CareMore. They typically have 250 patients.
2. DPC isn’t supportive of population health management. As mentioned above, DPC providers such as Iora Health are some of the most effective population health managers around. In contrast to the myth that DPC skims the cream, it’s actually the opposite of that. For example, unions have been among the early adopters of DPC models. They work with organizations such has Iora Health and Qliance to identify their highest cost members and put them into team-based care models strikingly similar to CareMore. I would argue that DPC care teams are more prepared than traditional primary care teams who have been operating in fee-for-service models. In fee-for-service, they do the opposite of what CareMore discussed. That is, fee-for-service primary care providers are referral machines.

Example # 3: Indian Health Service Funded Organization Wins Baldrige Award

Read more about the Nuka Model in DIY Health Reform from Massachusetts to Alaska. Following the link will get you to videos from the leaders of the Nuka model describing their approach. You can also read more about the Nuka Model in Family Practice Management (PDF) and Indian Country. The following are excerpts from those articles.

The system’s results—measured from Nuka’s start to today—speak for its strength: 50 percent decrease in visits to specialists, 40 percent decline in urgent care and emergency visits, 30 percent drop in hospital days and admissions, 20 percent decline in primary care visits, and 92 percent employee and customer satisfaction rates.

“Prior to our redesign, the SCF medical system suffered from one of the key problems in health care today. The system misunderstood the core product as being tests, diagnoses, pills and procedures,” she said. “When individuals sought health care services, providers would take their signs and symptoms, perform a physical examination, and produce a different diagnosis. Then, providers would do what health care does really well: order a bunch of tests,” she said.

How Models Can Scale or be Replicated
The following is a summary of how models referenced above should scale or be replicated by others:

• Nuka Model: The SouthCentral Foundation has regular events in Alaska to teach other organizations how to replicate their model.
• CareMore: Wellpoint can use its massive scale and customer base to expand upon CareMore. In addition, the past president of CareMore (John Kao) has founded Alignment Healthcare which is designed to scale many of the successes CareMore achieved in tandem with other healthcare organizations seeking to replicate the CareMore model. A recurring theme I hear from forward-looking healthcare organizations is they are using the Obamacare funded programs such as the Pioneer ACO or Medicare Shared Savings programs to build their competency on the federal nickel and then are going all-in on full capitation with Medicare Advantage and other similar programs. As Dr. Jim Bonnette (Chief Medical Officer of Oliver Wyman) stated, “the government is going to be surprised by how fast Medicare Advantage programs grow.”
• Direct Primary Care: Both Iora Health and Qliance have gotten large funding rounds to expand their footprint. DaVita’s Paladina Health division is quietly expanding their footprint. In the near future, a national health insurer will team with a national player in primary care such as Walgreen’s to offer DPC at scale to consumers via a gym-like monthly membership fee taking DPC from a niche offering to a new model consumers begin to understand. Increasingly health-literate consumers will recognize the waste associated with doing the equivalent of using one’s auto insurance policy for getting oil changed, new tires and other day-to-day needs. As satisfied DPC customers have learned, their monthly membership fee is lower than the co-pays one pay in insurance-burdened primary care.

In a follow-on piece, The Hot Spotters Sequel: New York Health Home, the New York program referenced above targeting the high cost, complex Medicaid population (1 million citizens) is highlighted. It will go into detail on the challenges they face and how they will overcome them. Already they are applying lessons from Camden, NJ and other areas that have had success. At the same time, given the unique challenges of Brooklyn, they’ll have new challenges to face.