To build successful Ontario Health Teams, we should look to Arizona

TORONTO – There are still a lot of questions about how the province’s Ontario Health Teams will function and how much they will accomplish. They’re supposed to reduce “hallway medicine” by improving the links between the various silos of healthcare – acute care hospitals, long-term and home care organizations, and primary care doctors.

But the teams are voluntary, and there are neither carrots nor sticks, no incentives and no penalties, for working together to improve patient care.

To see how OHTs could be tweaked and fine-tuned, one might look at the experience of Accountable Care Organizations (ACOs) in the United States.

Led by care-providers, often primary-care doctors and specialists, ACOs have been designed to foster teamwork among frontline clinicians and allied professionals. And the goal has been to improve the health of their patients while reducing overall costs.

To educate Ontario CIOs and technology experts about how this works, Orion Health recently brought a top manager from one of America’s most successful ACOs to Toronto. Faron Thompson, chief operating officer at Innovation Care Partners (ICP) of Scottsdale, Ariz., spoke to a group of Canadian healthcare technology executives here in October.

Thompson, who is originally from Sault Ste. Marie, Ont., noted that ACOs sign contracts with the U.S. federal government to take care of a certain number of “lives”, another term for patients. As they manage the patient, they are rewarded with “shared savings payments” if they meet specified benchmarks for cost and quality.

Importantly, if they provide care for a patient at a cost that’s below the benchmark, they can keep a portion of the money they’ve saved – provided they also hit the quality benchmarks.

At the same time, ACOs can be penalized if their costs are above the benchmark. So, there are both carrots and sticks when it comes to providing care.

For its part, ICP looks after 150,000 “lives” – a number that’s expected to grow to 210,000 in 2020. About 57,000 are contracted with the federal government.

In 2017, the cost of providing care to these patients was nearly 17 percent below the federal government benchmark – enabling ICP to keep close to 50 percent of the savings.

This made it the third-best performing ACO of 472 in the country measured by the cost-savings percentage.

But is ICP providing quality care at this cost? One good way of telling is to look at the readmission rate of patients to hospital. In Arizona, the average rate of readmission is 17 percent; for patients that ICP manages with its Transition Care Management program, the readmission rate is only 7.2 percent. That’s quite a difference, and a strong indication of the level of care ICP patients are receiving.

For his part, Thompson talked about how ICP did it, and which elements were needed for success.

To be sure, financial incentives for clinicians are important – and right now, that’s something missing from the plan for Ontario Health Teams.

At ICP, primary care doctors are paid quarterly care-management payments as an incentive. Depending on the PCP’s panel size, the payments can run as much as $20,000 per quarter.

The ACO model is heavily dependent on participation of primary care physicians to see patients, perform routine quality reporting and pay attention to quality and coding gaps.

The care management payments to PCPs help to offset some of the incremental costs to practices and provide incentives and reminders to physicians to stay attuned to the ACO’s unique needs.

ICP has another financial incentive for all participating physicians. When the ACO earns enough shared savings from a given payer, they will distribute the “gainshare” earnings to physicians and the hospital system that owns ICP.

However, in order for physicians to earn gainshare, they’re graded on their participation in the ACO on multiple measures such as use of the electronic health records system (i.e., how often they’re searching for patient records), their timely quality reporting, whether they’re attending meetings, and other metrics.

“They have to demonstrate participation in our programs, they have to be a good citizen of the ACO,” said Thompson. “If you don’t earn your points, you don’t pass go, and you don’t collect $200.”

The model is working – ICP has attracted about 2,000 physicians. About 1,700 of them are in private practice, working for themselves, while 300 are employed by the health system that wholly owns ICP.

Primary care physicians receive regular “face-to-face” performance reviews, showing them where they have done well and where they could do better. “We’ll kick people out, too,” said Thompson, observing that as many as 120 physicians annually are asked to leave. “You have to be willing to terminate physicians who don’t participate.”

He added that, “While we don’t want to terminate anyone, we must be willing to do so, and even more are asking to join the ACO.”

Thompson believes that sharing patient information among clinicians and allied professionals is of paramount importance. For this, it makes use of an electronic patient record system and integration engine supplied by Orion Health.

“We call it Innovation Exchange, and there are about 20,000 patient searches each month,” said Thompson. “It collects a lot of information from disparate sources – and there’s a huge amount of data in it.”

Another important technology is a web-based e-referral solution. It allows GPs to make referrals to specialists in the system more easily, and ICP has the benefit of referral visibility to help improve in-network referrals.

Something ICP has learned about electronic systems, in order to get physicians to use them, is to keep them simple. “Physicians don’t care about bells and whistles,” said Thompson. “They want to see their patients and get to the most important data quickly.”

Moreover, I.T. training sessions should be kept to a maximum of 20 minutes – not three hours.

Importantly, ICP makes use of analytics to gauge costs and clinical outcomes. In this way, it helps determine whether various practices and therapies are working well or not. “You need analytics,” said Thompson.

When it comes to gathering information from doctors, quality of reporting “is one of the things we’re paying them for.” Only by collecting high-quality information about diagnoses, tests, treatments and outcomes can ICP gauge whether it’s doing a good job. And it’s the data that shows where improvements can be made.

Indeed, the organization is committed to “evidence-driven medicine” and makes decisions based on its data.

It produces reports on these findings, and physicians are expected to convince their peers to switch to the best practices. For example, when it was found that a generic for treating macular degeneration was just as good as the brand name medication, but available at far less cost, it spread the word that physicians should change their prescribing practices.

Also, on the technology front, ICP uses a simple, secure communication application called TigerConnect, which connects ICP clinicians. It has become wildly popular.

“It’s like SMS, but secure,” said Thompson. Using it, clinicians can send messages and photos – such as pictures of patient rashes to a dermatologist for a quick consult.

“Dollar for dollar, this has been our highest-value return on I.T.,” said Thompson. He explained that clinicians are using the system for curbside consultations, which are unpaid.

The benefit to the specialist is that he or she builds a stronger relationship with the primary care docs. For the GP and patient, it means a question can be answered very quickly.

“The satisfaction with this has been phenomenal,” said Thompson. Not only are patients happy with this, but in many cases, the curbside consults have eliminated a trip to the hospital.

As ICP works hard to ensure that patients stay healthy and out of hospital, it’s making good use of “transitional care managers”. These are RNs and licensed medical social workers who bridge the gap between the hospital and community, and when patients are discharged from hospital, they ensure the patients have what they need to avoid readmission.

“When the patient leaves the hospital, our transition care managers look into whether they have care at home or whether they need home care visits,” said Thompson.

“They check on their meds, and make sure the patients can get them when they’re needed, and even if they have money for them. They’ll look at if they have a follow up with a doctor, and if they can get there,” and many other things.

High-risk patients will be identified – those who appear more likely to return to hospital – and efforts will be made to put them into special programs, to improve their health.

In a real innovation, ICP uses Care Coordinators assigned to primary care offices. Care Coordinators are specially trained medical professionals like Medical Assistants or former military medics. The Care Coordinators develop long-term relationships with moderate to high risk chronic condition patients to help improve their health status.

Part of the program is also paying great attention to the social determinants of health. “We’re finding out everything about our patients, including their cats and dogs,” said Thompson. He talked about one patient who hadn’t had a follow-up visit with a doctor in six months. It turned out that she was afraid to go out and leave her dog alone. In that case, a dog sitter was arranged.

In another instance, a hairdresser was brought in for a woman who hadn’t had her hair cut in some time – it was the reason she wouldn’t go in for a routine PCP visit.

“Our Care Coordinators can help with mental health and depression,” said Thompson. He discussed a COPD patient whose depression was brought down from 20 to 7 on the PHQ-2 scale after ICP managers arranged to get him a special device for use in the home. “He also went on vacation for the first time in five years.”

Not only did that help the patient, but the improvement in his health also saved the healthcare payer $70,000 a year.

All of these elements – evidence-driven medicine, physician performance, links between caregivers – are dependent on information and computers. “Technology is a major enabler of our success,” said Thompson. “We couldn’t do it without all kinds of great technology.”