In this episode we hear the second half of the conversation between CHESS’ own Melissa Pollock and Advocate Health’s Vice President of Population Health Midwest Megan Reyna as they discuss navigating the data and quality measures for success in Value-based care.

So Megan thank you so much for coming back to the Move to Value podcast. I'm really excited to talk to you a little bit more about population health at Advocate and curious - we did talk last time about ACO REACH. I was just curious a little bit about provider buy-in. How did you message ACO REACH and the model to providers? What did that look like? How were you able to get providers on board with this new innovative model?

Thanks for having me back, Melissa, happy to be here. Yes so everything that we do within population health in the Midwest really goes through a strong physician governance model and it is a true partnership with our physicians to participate in in in our value based care contracts. So ACO REACH as well, we really educated the practices who we thought would be good participants based on the data that we talked about last time to participate in ACO REACH would benefit from this program and we had conversations with them, really educated them on this program and the why and what the wraparound services would look like and then we continue to have conversations with them around what where we need to innovate within this model. The Medical Group as well because our Medical Group does participate in both Wisconsin and Illinois again in the areas of Milwaukee and then the South side of Chicago around what their needs are and really um what the practices, that entire care team, is needing umm in order to help patients manage their chronic diseases. And that's a conversation that we have with our practices and we continue to look at our data to say what are we seeing within the data to provide different services as we move forward. It will be a care model that continues to iterate um as we move along within this program to make sure that we're successful and patients are getting the needed care that they need.

Did you find it difficult to get providers on board with downside risk or, I know you mentioned in the last podcast that you guys have been doing capitation for a long time, but I didn't know was there any pushback that you felt or any kind of hurdles you had to jump over in those conversations with some of the providers maybe some of the independent ones?

So our aligned practices that are participating we did have um intentional conversations around capitation for this population. This is a population we were very intentional with what population we were participating in and this is a tough population that often is not going in to see the primary care provider. And so you know I think COVID also um brought a unique opportunity for our physician practices to think differently about capitation and what are benefits of capitation and so really looking at this population and providing an upfront payment to those practices, we are in total care um capitation for ACO REACH, um really provided them an opportunity to think differently. And I think our strong history with value-based care contracts and success that they've been able to see they were able to view it as a true partnership. And it wasn't a one and done we meet with these practices on a monthly basis and we are continuing to look at the finances and make sure that our model makes sense and that they're successful because if they're not successful within the model then the model isn't successful for us and so they really need to be able to provide the needed services and say something's working or not working um for the success of our entire project participation.

So, you guys are really providing data to those providers on a monthly basis of performance I would guess and metrics, is that right?

Performance, metrics, financial data and what they're seeing for the patients as well, so it's a two way conversation is that it isn't just us going to them to provide information but really what they're seeing and feeling with their patients and what's the information that they need to provide us that's working or not working. And so, you know, is the model of care working? Are they feeling like patients are getting the needed services? Are patients not coming in for a certain reason? That they need the support from us to be able to provide a new service or, you know, are they financially viable within this model or is this something that they need us to relook at with our financial um our financial model and really making sure that they're successful as well?

Yeah that I think that makes so much sense and you know I, being in this space for a while as you guys have been, I think one of the challenges is every iteration of contracts has their own metrics and their own quality measures that they want to be measured against and usually from a provider perspective we hear I don't want to look at the insurer when I'm treating a patient, I want to treat the patient that's in front of me. So, are there ways that Advocate has really approached these, you know, disparate quality metrics that are across multiple MA contracts Medicare contracts to try to help focus providers in?

Yes. So this is a great point and taking quality, in particular, we every year put this massive spreadsheet together that says what are the different quality metrics across all of our value based care contracts and we we're in value based care not just for Medicare, so not just 65 and plus, but also with Pediatrics which I think grows that that list beyond just you know the adult metrics as well. And I think last year it was like 74-78 different quality measures, and that's too much for a primary care, even the specialist physician to participate in value-based care. It's just too much of and you know what's the different metric here versus here and the reason why. um So what we do is we narrow that scope um too and we look at primary care and then we look at specialty care as well and we narrow that scope and primary care because we include Pediatrics is about 20 quality measures, and it's really the intention of what are those measures within the value based care contracts that we're trying to get at, and what measure is measured in every value based care contract which it's A1C control, and so we need to make sure that one's on there, but when you get into A1C control you can get into is it greater than 9? less than 9? less than 8? Right? ?hat does control really mean? And so what we do is we go through our physician governance that I spoke about earlier and really getting the buy in of the physicians as to what measures matter to them when they're actually seeing patients. And then we tailor those measures, we use national measures, tailor them to those twenty and then measure across, and we try to measure across all of our value-based care contracts our Medical Group looks at all patients all payers, to make sure that it's really about the processes and how we're providing the care versus one particular measure within a value based care contract. Now we do have a quality team that also supports that measure development and really that measure of performance and that quality team might focus centrally on a specific population or a specific measure that might be different than how we're measuring it um within our how we're holding our physicians accountable, but that's then on the quality team versus on the practicing physician.

Gotcha. So, it's a little bit different what's seen at the provider level as opposed to what we're having to report back to payers which that completely makes sense. I have a kind of off the cuff question. I know CMS a couple of months ago put out this blog about, I think it was like the universal quality metric set that they wanted to come up with or to propose, I'm probably calling it the incorrect thing, but I didn't know what were your thoughts about that if CMS imposing kind of a universal set of measures across not just Medicare but MA and down the line?

Very happy CMS is thinking about this because nationally this is what we've been asking them to do. um I think they need to focus. I think it's a good start, I'll put it that way.

Agree

I don't know if I think all of the measures are perfect but I think it's a really good start as to how they're thinking about this and you know I I'm happy that they're looking at MSSP and MA and they're looking at pediatric measures, as well, so that means Medicaid right, and they're looking at what are all the different types of value based care contracts. It's got to start with CMS and then the other payers hopefully will follow suit after CMS does it, so it's a it's a really good start.

Agreed. Yeah, I think them setting the trend and kind of setting that benchmark and then letting it trickle down, I think it's historically what we see happen anyway so agree with you on that. For providers that are just starting out in value-based care or are just coming out of medical school and may not know anything about value-based care, just curious your thoughts on you know what's the best way to deliver the best outcomes for their patients is there any education work that advocate does about value based care for providers?

So, value-based care is a team sport. And it really the education really revolves around what does that team look like and what is needed to be successful in value based care and I think one of the strong things that Advocate Health and is particularly in the Midwest just because that's my history is what do we need to do and how do we need to iterate that team to help physicians be successful within value based care? For someone who's new just starting out it's really taking that first step forward and that you can't solve everything and if you look at the data within value based care it can be overwhelming, because it's what's the first thing that I need to tackle? And really it's just taking that first step forward to focus, choose something to move forward within the data that there's an opportunity, and just continuing to take that step forward. We've been doing this for a long time but every year we need to continue to focus, look at the data, where do we have opportunity, and take that step forward. And I'm continually surprised at the end of the year what we've accomplished within a year but then when you look at the data there's more that we still need to do and the that I think that's the important thing is that you just have to take that step forward within value and continuing to move forward to be successful and you're always going to have something else but it's really that team and how you bring how you bring that team together to innovate and continue to move forward.

Yeah. I think you said this in your last podcast that, you know, data underlies everything being done at population health level and that I think that's just so important for anybody any health system or any independent practice moving into value based care because, you know, you don't want to just first spaghetti at the wall and hope something you know what's going to stick? what can we do, you know, you really want to be intentional about, you know, the kind of interventions that you deploy for your patients and so that's so important to measure, look at it, let's affect that care, and then go back and let's measure it again see where we're at.

Absolutely and you know I've talked to other colleagues across the country who say well we can't do this because of X number of reasons, right? Well then that's fine there's another area of opportunity that you can improve upon. We started a lot of our journey within post-acute and reducing our post-acute expense because that was something we could get the entire system, the entire locale, you know, to rally behind right and so you've just got to figure out what is that first thing you need to focus on and then take that step forward and keep going because you're going to have opportunity around the next corner to succeed.

That's great! So as far as your personal role at Advocate, what do you feel like inspires you on a day-to-day basis to keep doing the great work that population health is doing?

So, I'm a nurse by training and what's really important to me is the impact that we're making on patients. And so it's always really important to me to talk about what are the care gaps and who's that patient story behind it and how are we helping to really make sure that we're moving the dial for our patients. So, it's those patient stories. it's making sure that, you know, when I wake up in the morning that it's not just about making money or making sure that you know this this person's happy here it's really about the patient and that's what gets me up in the morning and um you know I feel like now working within pop health that I'm actually making greater good than I was one patient at a time at the bedside and so that's what motivates me and keeps me moving forward

I think that's a powerful statement that you think that you feel a little bit more of a sense of doing good than you did at the bedside that's super powerful. I agree with you on all this account. I'm not a nurse right training but I really I think it comes down to this patient stories and even one patient story is worth it to when we hear those in our meetings we have our you know you guys I'm sure do this something similar where you have someone bring forward a patient story of how care has been affected and how it's affected this one person and when you get to that that individual personal level I think it takes on a whole new meaning.

Absolutely yeah it's chilling you know you know you're doing the right thing

Exactly exactly. So, as far as the future, what do you feel like is the focus for the your population health team kind of in the next five years looking forward?

Great question. So really looking at how we optimize our chronic disease management across the continuum. So one of the things we're really working on now is renal care. So you know and there's a lot of focus with different healthcare disruptors on the end stage of renal care and that's absolutely important, there's lots of focus and you know, lots of disrupting to do in that. But one of the benefits I think with Advocate Health and really having that cross continuum look at value based care is looking at within primary care, how primary care can help impact renal disease and really making sure that we have early identification and that we have good handoffs and that nephrology has good handoffs back to primary care and that we're getting patients early transplants, and a lot of that starts within primary care and what are the services that we can provide for that patient across the continuum. So that's one disease state right? We we've got to look at multiple and so how do we provide that optimal chronic disease care across the continuum and then I think nationally as well is how do you specialists help support value based care? And really getting deep on value-based care with specialists, not just primary care. We've done a lot at the national level with Medicare Shared Savings, and it's often viewed as a primary care model and it's a platform to have value-based care across that continuum. And then I would also just say looking at that spectrum I usually say from birth to death but someone said it's actually should be from conception to to death and and really looking at um you know the the care that we're providing mothers who are pregnant and helping set that that baby and that person up for success for the rest of their life and really making sure that we're providing the needed services so that they can they can live a healthy life and manage whatever comes their way.

Great! Well Megan I really appreciate you joining us I think it's such a great conversation so once again thank you and I'm excited to hear in the coming years all the great work that Advocate Health is doing.

My pleasure! Thank you so much, Melissa, for having me.