Through CareConnect, its CEO says North Shore LIJ Health System now has new means and motivation to rein in expenses and enhance quality, two main population health goals.
For a provider organization trying to figure out the best ways to improve the health of its communities, having a health plan may be a distinct advantage.
The key objectives that are involved with successfully managing risk and operating a financially solvent insurance entity are strongly aligned with those of providers trying to improve patient outcomes and lower costs, says Alan Murray, president and chief executive officer of CareConnect, the health plan division of North Shore LIJ Health System, based in Great Neck, NY.
North Shore LIJ is a $7.8 billion, 15-hospital integrated delivery network serving Long Island, Queens, Staten Island, Westchester County, and Manhattan. CareConnect was launched in January 2014 and is the first provider-owned commercial health plan in the state. The health plan currently has about 30,000 members and generated $87 million in revenue last year.
“To a large extent [CareConnect] is about population health,” Murray says. “If you think about what an insurance company does, it is focused on assessing risk. Payers are very good at that because it is what leads to margin, profit, and growth.”
‘Insurance is Population Health’
Through CareConnect, Murray says, North Shore LIJ now has new means and motivation to rein in expenses and enhance quality, two main population health goals.
“We are figuring out utilization practices, medical management, disease management, and case management in order to manage risk in a very targeted fashion. Then we work with provider networks to incent and build in mechanisms and control to the extent that is possible the delivery of care that matches [various] risk profiles,” he says.
“When you take away sales, marketing, and all the administrative functions, insurance is population health. It’s a catalyst for population health because having an insurance company gives you all the infrastructure for [those] models. Also, you now have members who are paying money and have certain expectations, and you have to deliver on that.”
Data Analysis Improves Care Delivery
By using member data, CareConnect is identifying areas for improvement in North Shore LIJ’s clinical settings and helping the system implement programs to mitigate issues that could lead to inefficient care, overutilization of expensive resources, and less than optimal patient outcomes.
“From our perspective, there is a longitudinal approach to working with a health system on data. We start with big data and looking at the population as a whole to figure out patterns that affect quality and cost of delivering services,” Murray says.
For example, if there is a high instance of one- and two-day stays, CareConnect analyzes the factors involved and looks for solutions to prevent such short hospitalizations, which Murray says generally indicate that patients are not sick enough to be admitted in the first place.
“We do this not on the individual level, but on a global level,” Murray says. “We can start looking at why people are going to the ER—which is how many patients are admitted to the hospital—and look at putting programs into place to keep that from happening. This has a broader impact than looking at specific individuals who are high risk or high cost.”
CareConnect is also providing support to Care Solutions, North Shore LIJ’s care management organization that implements and oversees the system’s value-based care programs. On June 8, CareConnect began working with Care Solutions to improve care coordination for members who present in the emergency department or have an inpatient stay.
“Every time a CareConnect member shows up in the ER, CareConnect is made aware of it almost immediately,” Murray says. “We then communicate to the ER any information we have on that member… and Care Solutions follows up with support, such as scheduling an appointment with their primary care doctor within 72 hours and providing education on medications. Exactly the same thing happens in the inpatient role.”
Although the program is new, Murray expects to see solid results. “We are already starting to see some significant reductions in readmissions, and there is very high patient satisfaction with it, as well.”
Bridging the Divide between Payer and Provider
While Murray acknowledges that there is “no doubt still tension” between the payer and provider sides of North Shore LIJ, he says it has overall been “surprisingly easy” to work together.
“Having conversations with clinicians and people at the forefront of care is always difficult when you are coming in with data and ideas, but it’s monumentally different when you are integrated into the system. There is a trust level that is second to none,” he says.
Building on that trust, CareConnect is working with physician leaders who are now asking for data to help them define clinical protocols around the concept of value.
“They want CareConnect to provide cost data on several care pathways so we can help them work on the efficiency of care. They have never had to worry about that in the past,” Murray says, noting that physicians now understand that clinical practices that cost more without producing better outcomes should be reconsidered.
“It’s truly a model that is emotionally, clinically, and, I think, theoretically different because of that clinical partnership that exists [between CareConnect and North Shore LIJ’s physicians]. Even our medical directors are practicing physicians. Why do we do that? Because they should be.”
Another reason CareConnect has been able to break down some of the barriers that traditionally exist between payers and providers, Murray says, is that from the beginning the insurer has used North Shore LIJ’s clinical guidelines as its own. As a result, denial rates are in the “low single digits,” he says.
“From a provider and payer perspective, we are starting on the same foundation. That takes a lot of mistrust and heat away from that conversation because physicians know we at CareConnect believe denials are failures.”
Freedom from Contracts
As part of the integrated system, CareConnect also has the freedom to work with physicians to take a closer look at clinical protocols without being inhibited by contractual obligations, Murray adds.
“We can have a discussion about merits as opposed to figuring out the punitive impact of a contract not being followed. The relationship a hospital has with a big national payer is contractual. The relationship I have with them is progressive,” he says.
For example, if CareConnect decides to implement CMS’s two-midnight rule and pay for stays that are less than two days as observation status cases, “then that conversation would be based on data that looks at why that population is even in the hospital,” he says.
Date: August 19, 2015