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Yates Lennon, MD - Value Based Care Primer pt. 2
Episode 45th May 2022 • Move to Value • CHESS Health Solutions
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In this episode we continue our conversation with Yates Lennon, MD, President and Chief Transformation Officer of CHESS Health Solutions who discusses the seven pillars of value-based care and the questions physicians and health systems should be asking themselves when transforming from fee-for-service to fee-for-value.

At CHESS we often refer to the seven pillars of value-based care. What are these pillars and how does each impact fee-for-value?

So, we’ve tended to use these pillars, if you will, to think about the process. Really, it follows our implementation process in many ways. So, I would start with practice transformation. So, that involves ensuring that physicians, advanced practice providers, office staff from CMA to nurses to even front desk staff, has some awareness of value-based care, understand why it is important, and then are engaged in the process of transforming that practice to a infrastructure that supports the delivery of the value-based care models and success in those models, both clinically, which is ultimately what this is really all about, and financially.

From there, you can begin to layer on other services or pillars if you will. These don’t necessarily have to happen in this order, but we often start with thinking about quality. Most organizations today have some quality efforts already in place just due to primarily to the fact that CMS and other payors are pushing those. And most people have at least some pay-for-performance type of arrangements, where they’re paid for closing quality care gaps. But quality goes beyond just thinking about closing quality care gaps. For our quality team, we’re thinking about optimizing the annual wellness visit so that the template within the EMR is just capturing data points and discrete fields. That makes reporting easier back to CMS as well as to the private insurance companies, Medicare Advantage, as well as commercial.

We think about Care Coordination and as we define care coordination, that includes, for our teams, nurses and CMAs. They work together to assist also in quality. So, the CMAs help close quality care gaps throughout the year. They schedule annual wellness visits, that’s a big emphasis in the first half of the year. If you can already tell, that annual wellness visit is a key component of value-based care because it touches on so many different elements of value. The other role for Care Coordination would be moving with that patient, tracking that patient, outreaching the patient between transitions of care. So, patient is admitted to the hospital, discharged to the skilled nursing facility, then discharged home. Our Care Coordination teams are monitoring that patient as they transition through those different sites of service and ensuring that each transition is as safe as possible. We all know that medication errors, in particular, are a massive problem through transitions of care. So, ensuring that patients know what medications they’re taking, or supposed to be taking, and that they can afford those medications. If they can’t, then connecting them with the resources to be able to provide those medicines for them.

They also perform Chronic Care Management. So, that’s identifying. So, we can go back to population health, identifying a group of patients who are either at high risk or rising risk of a complication or with a certain disease state. Identifying those patients, and then on a regular basis, setting up telephonic or even telehealth outreach to those patients, so that between those four office visits a year, that a chronic patient might have with a provider in the office, someone is touching base with them throughout the year. As a clinician, I always think that way. That for an average chronic care patient, I might have an hour or two hours a year of face time with a chronic care patient. Whether that’s diabetes, hypertension, the combination of the two. That’s really not very much time over the course of the year. And so, when you think about the Care Coordination team being able to touch those patients in between those visits, you really are improving the patient’s experience of care. You’re extending the provider’s reach and ability to impact the patient in between those visits. So that’s a huge component of it. Those are the areas to date that we have largely focused. There are other services that can be provided, but those are kind of our building blocks.


We also think of another pillar as Pharmacy. So, CHESS, we’ve got a team of clinical pharmacists, PharmDs, as well as pharmacy techs. Those folks together as a team are focusing on medication assistance, so again working with a Care Coordination team, identifying patients who have trouble with affording medicines. Trying to ensure that we connect them with resources. Whether that’s community resources, or drug companies that have low-income subsidy programs, grants, foundations, other ways of accessing medications. Focusing on medication adherence, so in the quality component of the value-based contracts, medication adherence is about half of your quality points in a typical Medicare Advantage contract. They tend to be triple weighted, which means they have even more importance. So, it’s very, it’s critical to success that your patients are adhering to their medication regimens. So, that the team supports that work also. But then going beyond that, thinking about groups of patients who are at risk for certain complications with medications. One that always comes to mind first for me was something called a daily oral anticoagulant report our pharmacy team runs. Looking at patients with a new evidence of renal compromise that would indicate they may need to have their oral anticoagulant adjusted. If that doesn’t happen, then that patient is at risk for a gastrointestinal bleed. If they were to fall, at risk of an intracranial bleed. Those, both of those, lead to hospitalizations and even worse, potentially death. So, trying to identify those problems before they ever occur. Work with the patient’s physician to make a dose adjustment in their medications and avoid that downstream negative event.


We think and talk a lot about accurate coding. So, there’s a lot of emphasis on that. Has been for several years. It has gotten significant negative press as well. But it is very important that providers are accurately and completely documenting, first of all, a patient’s conditions, addressing those conditions, and then coding that. That helps align the resources to care for patients with the patient’s disease state. But it also, we remind providers constantly that in many ways today, the medical record serves multiple purposes. I’m old enough to remember paper charts and I was writing notes essentially to myself for that next visit, so I knew what I said, I knew what the patient’s problem was, and what we talked about, and that note was just for me. But today, it serves multiple other purposes. It’s a legal document, it’s a financial document, it’s a medical document. A lot more emphasis is placed on that documentation by the physicians and the advanced practice providers.


There’s, within CHESS we have an operations team. So, if I go back to practice transformation just a second. And that never is over with implementation, but that’s a big focus of implementation in the early phases as we prepare providers to onboard to the services I just discussed. That transformation is ongoing but after a period of time then our operations team steps in, picks up that physician group, and then shepherds them forward through the various contracts. Making sure they understand how the contracts work, make sure they understand how care is being delivered to their patients, and that the services we are providing are impacting the patient’s care as well as the financial performance within a contract. That really is implementation passing off and saying to the operations team, here’s the ball, you keep going.


And then I think finally, and this is not certainly not least, I’m just listing it last. At foundation of all of this is data and analytics. So, being able to ingest clinical data into a platform, pull in claims data from the payors as well as data from other sources, so HIE (health information exchanges), ADT feeds through vendors that are that have in their possession ADT feeds from various hospitals. Because we need to know where our patients are and be able to identify when they hit that facility. Especially if it’s outside our network. So that we know what’s going on and can reach out to that patient in a timely manner. And I think that’s the seven pillars.


I think you asked me also, why is it, why are these things important or how do they impact providers and patients. And we can talk more about that in just a moment, but to me this is work, most of this work is work that does not get done in a fee-for-service environment. There’re just not the resources, there’s not the infrastructure to support it. So, when you do this and do it well, you’re improving the patient’s experience of care and you’re also improving the provider’s experience of care, and extending their reach in a way that they would not ordinarily have to do it in a typical office setting.


What questions should physicians and health systems be asking themselves as they undergo the transformation from fee for service to fee for value?


Well, I think I would start with who are the beneficiaries for whom we are accountable. In our prior days, in fee-for-service, you didn’t really think that way. We were thinking largely about who’s on my schedule, is my schedule full, if it’s not full can we get it full. In this new world, we should be thinking about who’s not on my schedule that should be. If the patient is in a value-based agreement and attributed, or assigned, to the providers that have the agreement with the payer, then you’re responsible for those patients and their cost of care and their quality of care regardless of whether they come to see you or not. And so, I need to know the patients who are not seeing me for whom I am responsible so that then I can deploy my care teams to reach out, see if we can understand any barriers to seeing that patient, get them in, and get them the appropriate care that they need. We just never thought that way in a fee-for-service world.


I’ve alluded to this earlier, the next question to me would be where are our patients receiving care? We often get the answer, well I know when patients are discharged from my facility. And that’s probably true. But we don’t always know when they’re discharged from other facilities. It’s a blind spot for most health systems. That is improving today but we need to make sure that we are capturing data points, to the degree we possibly can, to understand that patient’s journey through the healthcare system not just the health system. Because if we don’t have insight into that, then we’re not able to respond appropriately when they’re making their transitions, whether that’s hospital to home, or hospital to skilled nursing facility. Whatever that may look like. We need to also think about clinical and cost needs. So, what clinical situations do they have that would be driving costly or high-cost care? How can we intervene? Are their behavioral health issues or concerns that we may need to address? Do they have poorly controlled diabetes or poorly controlled hypertension? So that we can get them to the right cost of care, the right site of low-cost care to intervene. Taking that a step further, what beneficiaries are at current or future risk of complications that could lead to high-cost spend. And then understanding what gaps in care exist for patients. That might mean screening tests that are open, that could be disease-state management, A1c and hemoglobin A1c is a great example of that. But it could also be patients lost a follow-up, patient doesn’t have the ability to afford their medications. So, addressing, identifying and addressing those gaps in care, whatever they might look like, is another important question that we need to ask as we, sort of, take that shift and shift our mindset over to a new set of questions.


In summary, you know, understanding where care is received, not just within our system, integrating that clinical and financial data together so we have a 360 view of the patient, and then beginning to use that to do some predictive modeling, both clinical and financial.


Value-based care is the right thing to do, and I believe this is true because of the impact it has on, what I would consider, two primary recipients of its benefits. The first is patients. Value-based care puts infrastructure and resources in place to meaningfully impact the quality of patient’s lives on a day-in, day-out basis. We hear this consistently through patient stories. The second is the provider, both physicians and advanced practice providers. Value-based care puts infrastructure and resources in place that extends their reach and their influence and impact in their patient’s lives. And at the end of the day, that’s what providers of healthcare want, is an improved quality of life for their patients.

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