In this episode of the Move to Value Podcast, we have a conversation with Robert Mechanic, MBA, Executive Director of the Accountable Care Institute, who shares ways to understand a patient population.

Transcript:

What is the Institute for Accountable Care and what is its primary mission?

So, Thomas, we are a fairly new organization. We're an independent not-for-profit. We were formed several years ago, and our primary mission is building on the available research and contributing to the available research on the impact of Accountable Care. Both to inform public policy and sort of future development of Accountable Care programs. And also, to support organizations that are committed to value-based care. So, I’d say, we combine, we’re a little bit unique. We combine elements of a think-tank, a data analytics shop, and a consulting firm. We like solving complicated problems, preferably using empirics, data analysis. Half of our staff are programmers, data scientists, and statisticians. And we like to work on problems that have practical implications for organizations who are trying to improve care or for national policy. And I guess, the last thing I’d say, our special sauce is we have a data use agreement with the Center for Medicare and Medicare Services, where we have access to 100% of the Medicare programs claims data. And obviously that allows us to ask all kinds of interesting questions and learn all kinds of interesting things.

How does your work document and promote the best practices for Accountable Care?

So, I’d frame the question, Thomas, a little bit differently. As you know, organizations can put best practices in place, but you know, whether they’re successful, it’s all about execution. And when we get into Accountable Care, everybody’s program, for example your care management program, is going to be different. So, what we can do, is we can help a particular organization, or a group of organizations, evaluate whether a particular program is achieving its performance goals. So, does your care management program improve quality? Does it reduce spending? And because we have all this data, we can do this sort of scientifically with a comparison group that we match to your patients, in your geography, and we can look at, you know, how their spending changes compared to the spending of the group that you enroll in your programs.

Another area that we do too, in this kind of work, is we help organizations develop and implement best practices through learning collaboratives that we organize and we facilitate. So, two examples of that would be we work with a group of a dozen ACOs building home-based care programs, and we bring in outside experts, but a lot of the work is also peer-to-peer. ACOs helping each other. They’re working on the same problems. And we’re currently doing a collaborative working on addressing the social determinants of health and how do you build a strategy, and how do you build the right infrastructure to have an impact.

How does the Institute for Accountable Care partner with Accountable Care Organizations?

Yeah, I mean, I think there are a couple of other areas. One is, you know, because of the data, we can help people understand their own performance compared to peers. So, an ACO, or a group like an ACO, has all their own data, of all the utilization of their patients, but they don’t really see everything else that’s happening around them. So, what we can do, is we can, you know, look at other providers in their market, or we can look at other providers nationally, that are trying to do the same thing that they are, and we can say, gee, you know, are you doing better or worse than them? Can we identify why? Are there certain areas, you know, you are doing great in managing hospital care, but you’re not so good in keeping people out of nursing homes and rehab hospitals. So, we can help organizations with that, we have a number of partnerships. We’ve also built a whole infrastructure to model the benchmarks, which are the spending targets in Accountable Care programs. And so, we work with some ACOs to help them think well we’d like to, you know, we’d like to add all these groups to the ACO, how’s that going to affect our spending target? We want to start a brand new ACO. How many beneficiaries would this ACO be able to bring to the table and you know, what is our cost profile look like? So, we do that kind of work with individual organizations, and you know it all ties back to the data and being able to ask questions of it.

During your presentation at the Move to Value Summit, you talked about how the concept of “regression to the mean” can undermine the use of historical expenditures as a way of predicting future spend. Can you touch on your findings again briefly?

Sure, absolutely. Well so, regression of the mean kind of is a term, it’s a concept, for people who are, groups of patients who are very high spending, tend to move back towards the mean spending naturally over time. So, when you look at your highest spending patients, those people generally have had, you know, serious acute illnesses. So, they may have been hospitalized. They may have underlying chronic conditions, in fact, many or most of them do. But it’s the acute spending that really, or the acute illness, that really drives the high spending.

So, a lot of those people, they get sick, they spend a lot of money, and then they get better. And so, they revert back to the mean. That’s important because, you know, some people will say, well let’s just, you know, let’s do a pre-post, and let’s look at these patients. Gosh, they’re high cost. Let’s put them in our program. Look how much we saved. And it’s very important, in the old days, you know, there were companies that did disease management. And they’d come to organizations, we can do this, and they’d show them pre-post data. And wow, we save 40%. But if you would have done, had no intervention with those patients, their cost still would have gone down.

So, you have to dig a lot more, dig deeper. And again, what researchers do, is they, the gold standard is a randomized clinical trial, but what researchers in the absence of that will do is we do a matching process where we find patients that have the same characteristics, you know, demographics, same clinical issues and comorbidities. And we track that same group over time, and we see, well how much does the comparison group, they may go down, how much does the control group, the intervention group, go down. And, so that allows you to have a more fair, apples to apples comparison, between the two groups.

So, you know, I guess my take home point is you can do pre-post in the very early stage just to get a sense of what’s going on, but it’s not telling you the whole truth. You really have to do a scientific evaluation. And, you know, if you don’t have the data yourself, you have to look to other partners, a group like us, universities often times have data and can do this. But, you know, you have to really ask the questions in the right way.

What advice would you offer to our listeners if they are seeking to identify patients within their populations who are at risk of future spend?

Well, so, Thomas, even though I’m a data guy, I think it’s very important to combine work that you do with data with input from the people who know the patients the best. So that means, you know, their doctors, their nurses, and their families.

I think it’s reasonable to look at historical spending, and look at patterns of spending, as part of the question that you’re asking. But you also, you know, you want to, I think you want to dive more deeply. And, you know, what I talked about at the Move to Value Summit, I was using fairly simple examples. There are, you know, there are companies and organizations that are doing kind of very, more sophisticated data analytics to try and pinpoint people who are not going to not regress to the mean. And there are companies like, you know, IBM Watson, you know the best computing resources in the world. But as you know, they’ve had a little bit of a tricky time. You know, they were trained to predict what’s the best oncology pathway. Well, that didn’t work out exactly like they thought it was going to be.

So, I think, you know, there are limitations to what you can do with data alone. And so, I think what you have to do is really combine, you know, careful monitoring, clinical input from the people who know the patients both, and you know, some understanding of their past and current spending history. And that’s the best, and combining those three things will be the best way to predict going forward.

Also during your presentation at the Move to Value Summit, you talked about Waste Reduction Strategies in reducing cost. Can you describe how provider groups might identify opportunities to reduce waste within the populations? Can you provide some examples of successful efforts to eliminate waste?

Sure, well, Thomas, so I think a couple points I’d like to make just to start which is that reasonable people can disagree about which services are wasteful and which services aren’t. And the second thing, which is really key, is that, you know, one person’s waste is another person’s paycheck. And so, you have to balance those two issues. I think that, you know, identifying waste, you can look at your population. So, we can look at sort of, on a population basis of per member per month or per member per year. You can look at use of high-cost services, avoidable hospitalizations, you know, hospitalizations that could have been managed with primary care if people did it in a timely way. Excess post-acute care utilization. We once looked at a hospital that sent 85% of their joint replacement patients, they were discharged to an acute rehabilitation hospital. And you know, nationally, you know, far less than 10% of people go to a rehab hospital. So, they of course had their own acute rehabilitation hospital. You can look at excess use of hospital facility-based ambulatory care and ancillaries, which generally cost twice as much as the same services provided in the physician office. You know, lots of high-cost imaging studies, for example.

So, all of those things, I think, are red flags that there may be potential waste. And then, you know, in terms of managing the waste, there are a lot of things you can do. You know, on post-acute care spending, I think, you know, really asking the questions. Does this patient need to go to a nursing home or are they safe to go home with support? Could they, you know, send home-health providers or could they, you know, even go and get outpatient therapy? And really ask those questions. Other things you might do, you know, curbside consults with specialists. So, you know, that is something that Kaiser Permanente has done for years. Primary care patient has somebody in for a visit, they notice something, they call the specialist down the hall, comes and takes a quick peep. Patient doesn’t have to go and, you know, schedule another visit and incur more costs and health systems can do that, you know, actually through e-consult systems. So, you know, you can, and what you are doing is really, the specialist doesn’t want to see a patient who doesn’t really need to see them. So you’re, you know, avoiding low-value visits to make it much more convenient to the patient. So those are, you know, those are just a couple of things you can do to manage waste.

Can you describe how non-medical in-home visits might impact quality in health care?

Yeah, I think that there are a number of ways that it can improve quality. So, one, is building trust with patient. And, you know, a lot of patients frankly are distrustful of healthcare systems. Particularly, you know, if they are in, you know, low-income or minority populations that, you know, have had bad experiences with the system. A lot of the time, sending non-medical staff for in-home visits, organizations will try to, you know, they will hire staff from the same neighborhoods that have, you know, a similar lived experience. So they may be, sort of, culturally sensitive to the patients that they’re visiting. And it’s also, you know, it’s different from being in the office where there is a little bit of a power dynamic. You know, people look up to doctors. They may not want to tell them things that they find embarrassing. Whereas, having somebody who, you know, you feel like is kind of like you, coming in, it’s more of a low-stress environment. And it also provides the medical team with some eyes and ears. Because when you go into somebody’s home, you really can see what’s going on with them. You can kind of get a better feeling for some of the things that may be affecting their health that they don’t necessarily see in a formal medical visit. You know, does the patient seem to be a little bit impaired? Do they have, you know, an abusive spouse or somebody else living in that house? Is the housing, you know, their home unsafe? They’ve been falling, oh gee, look, you know, they could, if they had some simple things to grab bars and ramps, they would be much easier for them to get around. So that’s intel that you don’t necessarily get in the medical visit. And somebody who can build trust in a patient’s home, can bring that back to the team and it can definitely improve care.

What advice do you have for providers who are trying to deliver the best possible outcomes for their patients?

Well, I would say, it takes a team to really manage a patient and care for a patient. Particularly, when they’re complicated, they have complex medical or they may have, you know, complex social situations. And so, I think team-based care is really better care. I think it can be better for the individual team members because they get to do more and learn more, and it’s more fulfilling. It’s better for the patient because they get different perspectives of people coming from different fields and different viewpoints. So, I mean, there is a lot of different ways. Again, I think, you know, a lot of quality and outcomes is systematic. Healthcare is so complicated, so can you build good support systems around clinicians. But also, there’s the personal dynamic of the team and building teams that communicate well, and are honest, and work effectively. I think its really important for organizations and for the workers themselves and for patients. So yeah, it takes a team to really do a good job at healthcare in the 21st century.