4 keys to sustaining financial viability in the shift to value

• A leading ACO in Texas has found a way to flourish despite systemic factors that can discourage value-based initiatives.
• One key to success is promoting strong connections across the care continuum.
• Other cornerstones include scale, a focus on innovation, alignment of incentives and integration of data.

In healthcare, the basic law of economics is sometimes flipped: Supply can drive demand. And nowhere is that inversion truer than in North Texas.

We have strong fee-for-service reimbursement and among the highest utilization patterns in the country. We also have a a passion for deregulation and a culture resistant to standardized care. In this region, our mission to transform healthcare into a value-based, data-driven system flies straight into a Texas-size wall of resistance.

At Southwestern Health Resources (SWHR), the clinically integrated network and population health management organization formed by UT Southwestern and Texas Health Resources, we’ve found an opening in the wall. We’ve developed a way to help independent and employed physicians across separate health systems shift to — and thrive in — a value-based healthcare system.

The key is connected care. SWHR creates connections between community and specialist physicians; among acute, post-acute and home-based care; and with community organizations. Those connections take the form of:

• Communications
• Shared technology, information and data
• Identified mutual drivers of operational excellence

Those points of connection must span the full continuum of care, from preventive to post-acute. Once established, connections deliver a better patient experience, better outcomes and lower total costs.

A 4-pronged approach to succeeding with population health

As one of the leading Next Generation Accountable Care Organizations in terms of savings for three consecutive years, SWHR has saved CMS nearly $120 million since 2017 while creating value for our acute care parent organizations, community physicians and purchasers. That value is created without compromising revenue.

To attain that balance and establish the connections that promote high-value, holistic care, SWHR relies on these four qualities and competencies.

1. Scale. Achieving adequate scale of resources, infrastructure, staff and market value is essential to driving change while maintaining financial stability.

With scale comes another necessity: full-time committed leadership. Small ACOs with part-time leadership, inadequate staff and insufficient data cannot muster the momentum, teams and tools needed to implement the changes that allow organizations to take on risk and lower the total cost of care.

2. Innovation incubation. Committed leadership also is needed to foster constructive, disruptive innovations in healthcare delivery. Maintaining the momentum around telehealth will require leadership after the COVID-19 crisis has passed, as will navigating disruption in where and how care is delivered and developing standards of care aimed at both clinical outcomes and total-cost-of-care management.

During the COVID-19 period, SWHR has expanded home-based care options, including developing new models of gap closure for cancer screening and chronic disease management to care for patients at home and work rather than bring them in for services. We’ve also worked with our post-acute partners to align them with our value-based journey via new accountability and tiering systems. And we organized our affiliated primary care physicians and specialists collectively around strategic programs, standardizing care with a deeper focus on both clinical outcomes and costs to eliminate high-cost, unnecessary services.

We use data to identify patients who would benefit most from new care delivery models like advanced geriatric care at home, community partnerships to remove barriers to care, and targeted care gap closure. Rising and at-risk patients are stratified using advanced analytics based on data sets that may include geography, claims, utilization and specific clinical comorbidities.

In short, we don’t wait for a patient to become a patient. Instead, we invest in proactive, preventive care that lowers total costs.

3. Aligned incentives — and mindsets. The more people in the boat rowing in the same direction, the better. At SWHR, rowing practice begins with physicians. They own the delivery of value-based care, the day-to-day interactions with complex patients. They are invested in solving the problems we need to fix to deliver value.

So, we give them a resource pool of care management, social workers, specialty pharmacy counseling and more. Then we align every other aspect of our organization to have the physician’s perspective: What can we do better to take care of each patient?

When a provider mindset is applied to the management of a risk-bearing organization, more resources are invested in the ambulatory setting. For example, we can set up systems that identify and invite elderly patients with diabetes into their primary care physicians’ offices more frequently, keeping them out of the ED and hospital.

We can align stakeholders — PCPs, specialists, care management and hospitals — by focusing all eyes on improving the patient experience. And we share our best practices, technology and analytics so that all of our affiliated providers can see exactly how we do it — and they can, too

4. Integration of data and information. Data analytics establish the impact to the organization’s bottom line of lowering the total cost of care as we shift the system away from a unit-based cost structure. We also use analytics to support physicians, delivering seamless, data-guided insights into their workflows. That’s about not only standardizing care but also giving every physician evidence-based, actionable information that’s easy to use.

With predictive analytics, for example, we are identifying the complex patients who need a COVID-19 vaccination right now — the people who both are eligible and should be at the front of the line during any given phase of the vaccine rollout. Then, clinical and claims data tell us if a patient needs a ride to get their vaccine or if we should vaccinate them at home.

By integrating our financial and clinical data sets with demographic data, we can create new models of risk and new triggers for earlier, more effective interventions.

Deriving value from population health management

With those four elements in place, population health management organizations can deliver the right care in the right place at the right time — whether that means telehealth, home-based care, ambulatory care or acute care. Organizations can calibrate care to each patient and encounter and be proactive in preventing acute illness.

How do our sponsoring health systems find value in this model? Delivering a superior patient experience grows the number of covered lives in our network. When we cover more lives with appropriate levels of care, inpatient beds stay full thanks to a broader total basis of lives.

It all comes down to focusing on the total cost of care, which means aligning all parties to ensure appropriate utilization. It’s a very different way of looking at healthcare costs. And it works.