Dr. Peter Goldbach is the Chief Medical Officer for population health management (PHM) vendor Health Dialog as well as convenient care provider RediClinic, both of which are subsidiaries of Rite Aid. His previous experience includes 15 years in payer and vendor leadership roles and another 17 years maintaining a primary care and pulmonary disease practice. At Convergence, he will address the roles of PHM as well as convenient care in advancing fee-for-value (FFV) care.
Why is it important for the healthcare industry to take the emergence of payer-provider convergence seriously? What do you see in your work that makes this important to you?
It may be useful to think of this as a re-convergence. In the longstanding fee-for-service (FFS) model, providers were set up to maximize fees based on the provision of care, and the roles of providers and payers converged or synchronized over time based upon that model. Now that we’re facing a change, providers and payers need to work together to achieve a new goal of FFV care. As a result, we see the need for re-convergence of all the stake holders in patient care.
Health Dialog was founded to help risk-bearing entities manage populations. As population health managers, we provide practical services that reduce cost and improve quality while enhancing the patient experience. We measure and report the value we create for our risk-bearing clients. With FFV contracting, provider groups are finding the need for these services. Managing this convergence will avoid duplication of services – as providers and payers share this responsibility.
RediClinic was a pioneer in convenient care. At its inception, convenient care had not “converged” with the broader community; Payers didn’t initially pay for the service, and provider groups were either opposed to or not interested in a relationship. Now we’re seeing tremendous convergence! Stakeholders see clearly the value convenient care delivers, recognizing it as an incredible opportunity to improve access to care, find and treat disease earlier and identify and close care gaps that may exist.
Many ACOs now view convenient care as an attractive addition that increases their ability to deliver low-cost primary care in their networks. The resulting convergence in retail health has had an immediate and profound impact on patient care and the patient experience.
Which stakeholders need to be at the table when strategic conversations about convergence take place?
When we define and refine the topic of convergence, payers and providers are obvious participants. However, employers, patients and regulators all need a seat at the table too.
For providers, PHM is a fairly new discipline. As their FFV business continues to grow, they are increasingly interested in care management solutions that support the new goals of value-based care that place more emphasis on controlling costs and managing chronic conditions to help their population achieve better health.
As payers and providers move toward convergence on value-based care, a significant barrier to overcome is the provider’s need to continue to provide FFS-based care while encouraging the successful implementation of FFV-based care. Payers are population managers by nature, and bring that strength to the table. Payers will need to assist providers in making the transition to FFV-based care as this will require investments in infrastructure, e.g. care management programs. Because providers have many payers to deal with, and they need to service many disparate contracts with different measures, achieving uniformity in quality measures is needed.
Employers play a key role. They are the group that has most effectively pushed for innovation – trying to find ways to be more effective in nudging the rest of the stakeholders along in getting a better product. As access to data and analytic technologies improve, we believe that new insights will drive innovative new approaches to care.
For example, a population-based analysis Health Dialog recently performed on a large national commercial population revealed that most of the medical expense over a five-year period actually came from the rising-risk pool or “silent population.” This segment is neither sick (and potentially covered by traditional care management) nor well; therefore, they’re not a focus of many wellness programs. These are people with pre-conditions such as pre-diabetes or pre-hypertension. Alarmingly, healthcare spending on this segment rapidly escalates over time despite the fact that these health conditions are amenable to lifestyle interventions. This finding helps underscore the need to provide care support to the entire population.
How is your organization beginning to focus on convergence? How widespread is the effort? Please provide specific examples, no matter how small.
RediClinic came to market years ago as a FFS offering. It offered convenient, high quality, low-cost care for common conditions; and it rapidly found a niche. Over time, payers realized that their members wanted this level of care, and the care was more affordable. Providers who initially resisted retail clinics began embracing them. Many ACOs seem to have the same strategy of expanding their primary care in a time of primary care shortages in order to welcome more patients into the ACO. Many ACOs now view convenient care as an attractive addition that increases their ability to deliver low-cost primary care in their networks. The resulting convergence in retail health has had an immediate and profound impact on patient care and the patient experience.
Forty percent of the patients that come through our door at RediClinic aren’t aligned with the medical system; they don’t have a PCP. PCPs in turn refer their patients to our clinics for off hours or minor illnesses. Now, as we work with our ACO partners, we’re starting to converge data sets to improve patient care; when patients show up in our clinics, we’re already aware of care gaps and can help close them. The potential impact of this level of convergence on community health is profound.
That same convergence of payers and provider innovators is now just starting with telehealth services, an innovative approach to care that is often not covered or covered well by payers. At RediClinic, we’re continuing down the path of expanding access to high-quality care. Telehealth is the next frontier for convergence.
What types of technology solutions are most critical for your organization to pursue initiatives relative to convergence?
For convenient care, our systems offer mobile-enabled appointments and appointment reminders. We are also working with our ACO partners to fill the quality gaps of patients who appear in our retail clinics. Using that clinical encounter, we can help patients fill those quality gaps.
For population management, Health Dialog’s analytics engine, which we call Care Pathways, segments a population into one of nine stages based on a person’s progression from well to sick. This allows us to highly personalize both the engagement and the care we deliver. A “Click to Coach” technology allows patients in wellness programs and condition management programs instant access to our nurse coaches. We are currently working to incorporate EHR, patient reported and monitoring device data into our analytics engine, which will help us offer interventions to patients that are even more tailored to their needs than previously achieved.
Do you think the roadblocks to broader acceptance of convergence are more strategic, tactical, operational, or cultural in nature? What are some of the roadblocks you’re encountering? Internal factors? External factors?
I suspect that most view the market as moving toward FFV at some kind of pace yet it faces a lot of challenges. In a former role, I led an informatics company. At that time, a lot of health plans knew their data wasn’t optimal and they needed to improve it. That’s an operational problem.
For providers, a huge roadblock is financing the change in healthcare. Many providers are reducing their workforces due to financial challenges. EMR and other IT investments have limited the spend on needed care management services
Uncertainty about the pace of change and support for various government programs has been a problem, too. Things have moved a lot slower that we thought they would.
What is driving this more: public or private payers? How much interest do you see in this as a mandatory vs voluntary process?
CMS policy has clearly been a consistent driver towards value-based care.
Regulatory requirements certainly drive change, but they can also pose barriers. Telehealth offers tremendous opportunity to increase access to quality healthcare even beyond what retail health has achieved. However, regulations must evolve. States are taking action but this is an instance where the federal government may drive change.
Another example of where government may drive change is shared decision making (SDM), a 20-year-old practice that’s been proven to help patients choose less invasive care, achieve better outcomes when they choose surgery and be happier with both their care and their provider We’ve been a pioneer in shared decision making since its inception.
The National Quality Foundation (NQF) issued a white paper in December, stating that SDM improved patient-centric care and certification of shared decision making aids was needed. In 2018, the National Committee for Quality Assurance will add shared decision making to its quality measures. A few years ago, Washington State recognized SDM as the most effective form of informed consent and gave it some regulatory cover. One or two years ago, it started to certify decision aids – with the hope that CMS will follow suit. Our hope is that with the NQF involved–and with better definition of what represents a decision aid—we’ll move from “check the box” process measures such as ‘do you have a program?’ to programs that measure whether effective SDM is in place.
What organizations other than your own do you consider to be leaders in convergence?
Group Health, now Kaiser Permanente Washington, has been engaged in shared decision making from a quality and patient experience perspective for many years. Leaders have taken the position that SDM is the right thing to do, and it offers a program that has delivered substantial outcomes in terms of patient service and cost savings.
Partners HealthCare is also a leader. It committed to shared decision making long ago—at the height of FFS—and embraced it because it was the right thing to do for patients. Its goal: match the right treatment to the right patient at the right time, every time. Partners recently published the results of its work in Health Affairs, which highlights the success in delivering patient-centric care.
Finally, the National Rural Electric Cooperative Association has shown tremendous leadership. The NRECA is a national organization of more than 900 consumer-owned electric cooperatives, which provide service to 42 million people across 47 states. It has offered advanced chronic condition management services to their members for many years, and are now more aggressively moving to serve its entire population with programs focused on wellness and diabetes.