There is more than one way to become an accountable care organization.
In the case of St. Joseph Hospital in Nashua, N.H., its first foray into active care coordination is not the result of a risk-based contract with an outside payer, but because it self-insures employees, and thus was already at financial risk for the health of many of its patients.
St. Joseph has many long-term employees who are now in their 50s and 60s, so its beneficiary base is relatively sick compared to the general population, CEO Dr. Rich Boehler said during an interview at HIMSS15 in Chicago.
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“We were wanting a better employee-benefit solution to reduce healthcare expenditures,” Boehler said. “We’re very committed to doing more than chronic disease management.”
St. Joseph Hospital covers about 1,800 employees and their dependents. Covenant has a total of about 6,000 employees and 15,000 covered lives, according to Boehler.
The goal is to keep people who are at moderate to high risk for developing a chronic disease from “tipping over” into a situation where they would need expensive, ongoing care like dialysis and to keep them out of the hospital, according to Boehler. “Once you have kidney failure, the jig is up,” he said.
Last year, the hospital, which is part of Tewksbury, Mass.-based Covenant Health Systems, a Catholic three-hospital system and network of eldercare facilities across New England, engaged MedeAnalytics, based in Emeryville, Calif., to help address the problem. Boehler met with MedCity News at the MedeAnalytics booth at HIMSS.
“We used [the analytics technology] first for plan design,” Boehler said.
“The biggest thing for this current year was plan redesign,” he said. Management wants to provide incentives for people stay in-network and see primary care physicians rather than going to the emergency room. “We will see the benefit of that 1, 2, 3 years out.”
Participants in management programs get a discount on their premiums, Boehler said.
Initial analysis identified an interesting pattern. “One of the toughest things we’ve found this year is that our employees do fairly well. It’s their spouses who have the highest-acuity cases,” Boehler said.
Data right now comes from insurance claims. “We’re mining a claims database, but we marry it with the clinical information in our EMR,” Boehler explained. “We’re able to risk-stratify.”
Patients at high risk of developing diabetes might be prescribed ACE inhibitors, Boehler said. With the claims database, the pharmacy can tell who has diabetes and is not filling the prescription, then case managers can find out why. “We get early warning if the patient stops taking meds based on fill records,” Boehler said.
He said there is a “fine line to walk” for administrators like himself to avoid violating the trust of the workforce. Boehler, who has not practiced medicine in the last four years, has administrative access only to the database, not clinical access, and said he does not want to know about employees’ clinical needs. “Care coordinators and care managers do,” he said. “It’s based on need-to-know access.”
[Photo from Flickr user Dan4th Nicholas]
