Todd D. Ellis
Editor’s note: On March 16th and 17th, 2017, Telehealth and Medicine Today convened a national conference of opinion leaders to discuss and debate “Technologies and Tactics Transforming Long-term Care.” What follows is a panel discussion with Pramod Gaur, moderated by Todd Ellis on the topic, population health management.
Todd D. Ellis [00:00]
What we’re going to talk about today is population health management. For the past two and a half years I’ve been working on the New York State District Program (DISRIP) focused on improving healthcare of the Medicaid population—focused on our reduced readmissions and visits to the ED (emergency department) by about 25% over a five-year period. My role was helping the 25 performing provider systems understand the technologies they need to use to provide better care to a segment of the population.
One interesting aspect, when you think about population health management, is that there is a lot that goes underneath that. And one unique thing about the DISRIP is that the PPS (prospective payment system) had the opportunity to pick projects (i.e., how they would be assessed by the state and how they would be paid) because this was seed money from CMS (Centers for Medicare & Medicaid Services) to make that program work. It was refreshing to see some of those PPS or clinically integrated networks pick projects that included telehealth or telemedicine. I think that was very refreshing.
I think telehealth will happen. I look back, and there was one point when I would go to my banking center and I would always want to go inside no matter what. Now, I haven’t stepped foot in a bank because of ATMs. So, I see telehealth moving in that direction. There will come a point in time where the consumer will demand it. I think we’re going to see more and more organizations use telehealth as a competitive advantage.
What I see in working with many different CMS in New York is that they’re trying to get a competitive advantage. They understand that telehealth may not be where it needs to be from a reimbursement perspective, but their vision is that at one point they’re going to get over that from a policy standpoint. They’re positioning themselves now to prepare and have their foundation for telehealth so when they make it over those policy hurdles, guess what, they will already out of the gate. Whereas, we’re going to have some hospitals that are just going to be starting once those policies have been put in place to support telehealth.
Pramod Gaur [02:18]
Thank you so much. It is great opportunity to be part of this distinguished group of panelists. Todd mentioned the DISRIP program. I don’t know how many people are aware, but as Todd mentioned, this is for re-engineering the Medicaid program and it is CMS funded. What’s interesting is the funding will be paid only if they achieve that 25% in reduced readmissions and visits to the ED over 5 years. A lot of organization working on this may not get paid if they don’t achieve the result. It is a very interesting concept that has been put in place, and there is a lot of activity.
On this slide (Figure 1) are the key stakeholders for a sustainable program. Once you are inside the four quadrants you have the patient or caregiver. You have providers: both the system, as well as the professionals. And then on the bottom you have the payers, regardless of whether they are government or private insurance. Then you have regulators.
Outside of this are the key industries all the way from consumer electronics, smartphones, and devices. There are health IT (information technology) companies. How do we integrate to the EMR (electronic medical records) that a patient generated?
Then, you’ve got medical devices: all these different wearable, as well as wireless devices. Then communication: the telecom companies also have interest in providing consumer healthcare.
Whenever we look at an opportunity, rather than just looking at the patient and caregiver, we ask if there is going to be an issue in adoption of this by the patient? Are there going to issues with caregivers, and how is it going to help.
Simultaneously, the next thing we say, OK, is something going to be useful for the patient and caregiver? Who’s going to be in the receiving facilities: the doctors and case managers? How are they going to be able to handle this information and get the positive outcomes? Who’s going to pay for that?
So that’s really on the right side and then we come down to the payer aspect. Earlier it was mentioned that payers are very much concerned about the cost. They’re also concerned about access and quality. But number one, they need to make sure it’s not going to add a lot of cost, whether it is government or private insurance or employer-based.
Then, we look at the regulators. In the telehealth industry, there have been a lot of examples. Each state has their medical board. You may have seen that Teladoc® took the Texas Medical Board to court because of the issue: how do you establish a patient-provider relationship?1 Many states are saying this must occur in person.2 Well, if that’s the case, these virtual urgent care types of service cannot occur because that’s the first time you’re seeing them. So, that’s the state regulator part of challenges.
Then, you’ve got legislative priorities, and there are some positive things here. You heard the discussion to continue to provide the telemedicine side. And the new administration and CMS administrator have shown positive interest.3 But at the same time, you have FDA (Food and Drug Administration) that plays a big role.4 Again, part of the information in you are collecting is HIPAA-controlled (Health Insurance Portability and Accountability Act of 1996). How do you work this through?
In the last few years the FDA has done a great job clarifying what we need to provide regarding the safety and efficacy of the solution, whether it’s software or hardware devices. They’ve done good in terms of trying to clarify what we will need.
So, this is the continuum: when we look at population health and you’re looking for sustainability this is the kind of filter that we put it through.
Todd D. Ellis [06:22]
One point I want to add is eight years ago I was working in Columbus, Ohio at Ohio Health.5 Telehealth has been around, I mean you’ve all heard of edict (electronic intensive care unit) because at Ohio Health they became such experts at eICU. They’re making money off that. They looked at many different hospitals in the region. And a point I want to make about that is this. When people say telehealth, you really must understand the strategy for your organization. How does it fit in, and where does it make sense for an organization to say, “I want to do telehealth?” You don’t want to bite off more than you can chew because it’s going to be hard to measure your success.
Now, a lot of organizations are taking one or two steps back. They’re trying to understand where they are now for a clinically integrated network: where the market is going for fee for service, value-based care, understanding how telehealth or telemedicine play into that. What can that organization take on? Because now you’re talking about resources. You’re talking about how telehealth is going to impact resources—the operational IT (information technology).
When you start looking at this “circle of life,” understand what’s important to the organization and what you can do. Be mindful. Don’t bite off more than you can chew. I’ve seen organizations do that, and I’ve seen their telehealth programs coming to a halt because, again, it’s just too much.
Pramod Gaur [07:48]
One of the trends happening now is convergence. Within the last few days I saw a press release. The University of Pittsburgh Medical Center has merged with one of the health plans.6 So, there is a convergence between the health system and the payer. This is still in the early stages, but there is an interesting aspect—creating a joint venture. And that’s the latest example, but that’s true with the payer (e.g., United Health Care, through their Optimum Health Care, which they own). That’s where they’re providing the care itself. And others have a similar kind of program.
And then, of course, there is as a subset of the bottom right, the VA (Veteran Administration) system where they are the provider and the payer. We have seen some of their success of being able to advance their telemedicine program as far as sustainability and extension because they have some alignment in terms of their incentives.7
So, watch out for health system and the payer alignment. This is still going to take some more working through because sometimes they are offering a program where they are a partner. But then, there is also the open market, which still needs to be worked out. There are certain regulatory constraints over what a provider and payer can and cannot do it. But it certainly is a step in the right direction.
And, as Todd mentioned, there are other examples where it’s taking us a while, but it has the incentive aligned across different provider groups within the healthcare system. So, one needs to look at it.
Todd D. Ellis [09:34]
It’s interesting. Now you have EHR (electronic health record) vendors partnering with payer organizations, but they’re building some unique telehealth capabilities.8 So, it’s not just the telehealth or telemedicine vendors who are in the market. It’s the EHR vendors who are putting that functionality in their platform. They’re partnering with certain payers. So, when you start talking about telehealth, it’s interesting see what’s really going on at all levels.
When you start seeing health vendors partnering with health plans and payers and understanding how a telehealth visit may be embedded into the EHR platform, we’re talking about you having a telehealth visit. Where do that data go? Where does that visit show up? But guess what, there are EHR vendors out there already thinking about that because they understand and they see that this is where the market is going.
Pramod Gaur [10:27]
So now I want to just shift a little bit to population health management and then zoom in for long-term care. Population health, as was mentioned earlier, there are so many different definitions. I want to give you an example that I’m aware of here in Westchester County in New York. We have a population of about a million people in Westchester, but we have about a hundred thousand Medicaid people in Westchester. Like in the whole of New York State, Medicaid is half paid by the state as a mandated requirement to provide Medicaid, but the county budget is 50% of the state portion.
As county executive, Rob Astorino, who is the responsible for caring for at least one hundred thousand Medicaid patients has engaged with us.9 He said that I understand for advanced stage coronary illness there are different initiatives going on. There are different ways to reduce readmission and so forth, but I pay for the entire population of one hundred thousand. So, we looked at one hundred thousand, and about 5% to 7% are what we called acute care. They are going in and out of the hospital. They are highest bill, but they are processed. What is not being processed are the 60% to 70% who are not utilizing health care services at all right now. But they have chronic conditions, and they just percolate until they get to this the acute stage.
Another 20% to 25% have multiple chronic diseases that may be in the early stages, but nothing is happening with this group of individuals. So, we started to look at and develop programs for those 60% to 70%. We need to connect with them and help them stay healthy: activity management, nutrition, and those kinds of services. But having information so that we have some record of what’s happening with them.
The second level is those who are living with chronic diseases. We want to know how they are maintaining their chronic diseases: their blood pressure, diabetes, or asthma, and things like that. What we are doing is collecting data points in a cost-effective way, and then feeding this into tertiary care or acute care when it is needed.
By itself, this is still very difficult and not cost effective, but this is where county social services partner with this program. They have resources from social welfare and senior services where they are reaching these folks. And then we can combine and create a cost-effective total population system.
The process is still ongoing, but the TIPS program has nine different sites in Westchester, some are senior centers, some are places where they come once or twice a week for senior centers, or they have their own community centers where they’re coming. And They are bringing resources there. They also coined the name, “assisted telehealth.”
Sometimes these folks, especially if you’re going once a week, they have no way of remembering to go to the kiosk for self-service like an ATM and enter their password. So, we provide the resources and collect the information. The data are longitudinally available.
Where we need to do more is to connect with the electronic health record. When they do show up in the tertiary care, it needs to be clearer. Right now, we have the information available, but it’s several clicks away. It doesn’t work unless it’s all integrated. So, that’s the kind of population health we are involved in.
Pramod Gaur [14:38]
Now I want to shift to the long-term care. Those who have not only advanced chronic disease, but need assistance—either assisted living or in skilled facilities. How do you use technology to get better outcomes for them?
When you shift to that population you’ve got, on the right side [Figure 2] are the sickest—mostly with three or more chronic diseases. That’s where most of the dollars shifts to. There are very few if any healthy people who need the skill facility or assisted care. This is where we start to focus on how do you interface with their uses of acute care hospitalization or rehospitalization, but then feed in from the from the left side which is very low in terms of dollars. By spending a little bit more money there can you reduce the right inside as far as the scope and cost. And you have average spending is in the bottom, but the sickest are the ones who are taking the most of your dollars.
Todd D. Ellis [15:43]
Could you describe other aspects of taking care of sickest with telehealth? There is another vertical that you got to look at.
Pramod Gaur [15:55]
Right. Those (on the right-hand side of this graph) are not only the sickest in terms of their medical condition, but they also have cognitive disabilities and daily living issues. So, they have other activities they need assistance in.
Some of them, if they happen to be still living in either assisted or independent houses, have resources coming in the home: health aides and others. So, one of the things we are doing in Westchester County is to see if we can leverage the home health aide or other caregiver to also collect some of the information that we know is able to help. It’s not just that our healthcare providers are doing traditional clinical monitoring, but we can incorporate this in other care models.
Todd D. Ellis [16:49]
We did what we call target operating models. Before the CINs (clinically integrated network) and PPSs took on a project they looked at what we’re doing in telehealth—that’s one of our projects. How does telehealth gets into the broader picture of what we’re trying to achieve, not only for the district but for the other populations? Because the district was for Medicaid. But let’s talk about how we can apply telehealth not only to Medicaid but to all the other populations. If you’re going to invest in this technology you want to use it as a whole.
So, we did the target operating model where we did just that. They were targeted to a population—how this technology would be impacted operationally and clinical. We laid it out. We documented the requirements from an operational IT view. We did work flows, and we even showed community-based organizations (CBO), because I think they’re so important when we start talking about managing populations, The CBOs are so important. You must look at what technologies they have because when you are managing a population that’s just not within four walls of the hospital, but assessing the community-based organizations and understanding how can they help you with your telehealth strategy.
Again, this is something that you need to sit down and think about and really focus in on. What can we take on as an organization? A lot of time that target operating model will put a spotlight on those areas where you may be weak or areas where you may need to have more attention regarding telehealth in that strategy.
Pramod Gaur [18:15]
Just to the last point that I have. As to the business models, those who are in the skill facility or assistance facility, traditionally, in their business model, they must fix sick people. Then, from there they went to the grave.
Now, with rehab and transitional activity, as Dr. Bakalar was saying, for example in the case he gave from Mass General, they are being released from the acute care to rehab center. Well, in a lot of these facilities, up to 20% of their beds are for this transitional care. So, they can provide some of the professional and the skilled care—as the question was asked, is patient is going home get into infection. So, they are in the facility with skill resources but at a lower cost level. And this is where telehealth plays and can play a much bigger role. You see how they are recovering.
As far as the technology aspect, it needs to be a horizontal platform, not only collecting their information but also having a video consultation, as was mention earlier, with the specialists connecting with this.
Todd D. Ellis [19:30]
So, I think organizations will mature about telehealth and its capabilities: how it can help with having quality care. And it’s not just about the ROI (return on investment). Those are the organizations moving in the right direction. They’re just making it a part of their culture. This is how we will provide care. This is one aspect of it.
Pramod Gaur [19:49]
A couple years ago I was invited to speak to the American Geriatric Physician Association. The outcome of that was that there was a follow up project that I’m working with some geriatricians. They have taken the person as a whole, focusing on eight different domains. The domain activities could be cognitive activities, risk of fall, and physicals, and so forth. We are trying to build that into this population model that I just gave you as an example for Westchester County. It is to collect this information and then at our connecting point we will have an analytic in the sense rather than saying, “How are you doing on this domain?” We say, “The last time you told us this. Has anything changed?” And we found this had a tremendous difference versus asking just an open question.
Those are the kind of things that we are looking at if we’re going to focus on a population, focus on a whole person. It is not only the clinical aspect. And so yes, we are using the tools and technology that you use in telehealth, but it’s really a lot broader if you’re going to address the population.
Todd D. Ellis, Principal, KPMG, is a member of KPMG’s DSRIP (Delivery System Reform Incentive Payment) support team to the New York State Department of Health. In that capacity, he leads the DSRIP IT Strategy vertical focus on developing IT strategies for performing provider systems (PPSs) as they look to adhere to DSRIP guidelines and protocols. Areas of focus include developing target operating models for PPSs, developing business and system requirements and use cases for IDNs, assessing various technology platforms and vendors, ensuring data sharing and confidentiality protocols are in place, fostering communication amongst PPS CIOs, and ensuring the alignment of DoH (Department of Health) DRSIP policies with the PPSs.
Pramod Gaur, PhD, is telehealth SME (subject matter expert) and Adjunct Professor, Pace University and Clinical Assistant Professor at Stony Brook University. Dr. Gaur was responsible for enterprise level coordination of telehealth common capability at UnitedHealth Group. Prior to that he served as the founding President and CEO of two telehealth companies: Viterion TeleHealth and Healthanywhere Inc. He is a visionary leader with extensive record of achievement in commercializing telehealth care, medical devices and diagnostics technologies. His activities as a telehealth industry advocate include demonstrations to the US Presidential Advisor, US Congress on Capitol Hill, The White House Conference on Aging and to International Delegates at the United Nations.
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