For years, Premier Medical Associates has been among the leading multi-specialty clinics in western Pennsylvania. But they weren’t satisfied with excellence in fee-for-service quality and cost measures. They knew they needed to position themselves to lead in fee-for-value, and that meant excellence in managing populations. By focusing on multi-disciplinary care management and using population health tools from Optum, Premier made the leap from simply providing care to actively managing health.
“We have always prided ourselves on leading the local market. But we know other organizations eventually will be able to do what we do, so we’re always trying to
stay ahead of the game,” said Frank Colangelo, MD, chief quality officer at Premier Medical Associates. “We saw that having this population health tool with sophisticated capabilities was the ‘next thing.’”
Changing focus from fee-for-service to pay-for-quality
Founded in 1993 in the suburbs of Pittsburgh, Premier has always focused on delivering high quality, efficient and patient-centered care. As its patient panels grew, the
clinic expanded and gained a strong reputation. But events in the latter half of the 2000s-decade changed the course Premier was taking.
First, a large chain of urgent care clinics moved into the area, leading to a number of Premier patients utilizing the new provider for acute care problems. As an example, year-over-year, Premier saw the number of patients complaining of sore throats drop by 75 percent. Second, the Great Recession of 2008 caused many Premier patients to lose their jobs and their health insurance, which led to another decrease in patient volume.
Around the same time, the largest insurer in western Pennsylvania began offering “pay- for-performance” bonuses to physicians. Under the plan, Premier could receive moderate payment increases — $3 to $9 per attributed member per month — if their care quality was found to be better than average for chronically ill patients. The practice reached
the highest level of quality within two quarters, and Premier began to see they had the capacity to be paid for quality. By the end of the year, Premier found that despite its losses in patient volume, it was in a better financial position than before. Helping the sickest of their patients better manage their diseases appeared to be a financially viable model.
Since then, Premier has continued to invest in quality. In 2011, Premier began the certification process for Patient-Centered Medical Home (PCMH) status and, at the
same time, began implementing its first electronic health record (EHR). 2013 saw Premier become the first non-academic practice in its region to have all its adult primary care locations certified as Level 3 PCMHs by the National Committee for Quality Assurance. Between 2011 and 2014, Premier rolled out its EHR to each clinic location, committing
to full EHR utilization so they could generate meaningful data.
While working to become a PCMH and fully implementing its EHR, Premier also took on major quality improvement projects.
Developing a data-driven, quality-focused culture
In 2013, Premier participated in the Centers for Disease Control and Prevention’s Screen for Life campaign. The campaign’s focus was on screening for colon cancer, the second leading cause of cancer deaths. Premier made outreach a priority for their patients above age 50, publicizing their screening efforts in waiting rooms and asking every qualifying patient at every visit when their last colon cancer screening was. They also internally published un-blinded practice-wide screening rates. The clinic’s baseline for such screenings was 57.5 percent at the beginning of the campaign. By the end
of 2015, 80 percent of their qualifying patients had been screened. The National Colorectal Cancer Roundtable recognized Premier for its efforts; Premier was one of only five organizations to receive this recognition.
In late 2013, the clinic also chose to participate in the American Medical Group Association’s (AMGA) Measure Up/Pressure Down campaign for high blood pressure. While some providers questioned whether Premier could focus on two quality improvement campaigns at once, Premier leadership felt that their structure and implementation methods would help the organization succeed. And they did succeed.
By implementing the campaign’s evidence-based actions and internally publicizing the control rate of every practice, Premier helped increase its patients’ blood pressure control rate from 62 percent in 2013 to 80 percent by the end of 2015. The effort led to Premier’s being recognized by the U.S. Department of Health and Human Services as a Million Hearts Initiative Hypertension Control Champion.
“We were betting that by taking better care of patients with diabetes and having them all on statins, there would be fewer heart attacks and strokes,” Dr. Colangelo said. “By improving blood pressure control, we guessed there would be fewer heart attacks. By doing more colon cancer screenings, there should be less late-stage colon cancers. We were hoping that we were going to start reaping the benefits of all of these efforts going forward.”
Premier developed a culture of quality and data-driven decision making by focusing
first on doing right by the patient. They implemented technology as they needed it to accomplish their goals. For example, the clinic implemented an EHR as part of its PCMH certification. The EHR gave Premier meaningful data on which it could make meaningful decisions. But it also had its limitations. Their EHR could not help them identify cohorts
of patients in need of care coordination and management. It couldn’t dig deep into its data stores to find patients with symptoms of chronic disease but no official diagnosis. It didn’t have predictive capabilities. These are all important capabilities when organizations embrace care delivery models requiring population health management. “Having monthly chart audits and follow-up sessions with our coders has been very positive. Our coders are just getting better and better.”
Using analytics to improve care management
Premier joined the AMGA Analytics collaborative in 2015. The collaborative for improving population health through comparative clinical analytics mines and compares data to understand how the highest-performing organizations achieve superior outcomes at a lower cost. Collaborative members share de-identified data so that
they can not only set baselines and goals using their own data, they can also compare themselves to other high-performing groups. To gain these benefits, Premier installed Optum® One, a health care-focused analytics platform that utilizes claims and clinical data to help organizations identify and manage at-risk patient populations.
At the time, Premier had built a multi-disciplinary care management team of nurse navigators and a pharmacist. The nurse navigators joined Premier in 2011 when Premier was working to become a PCMH. Each Premier primary care office has a nurse navigator on staff, as does the pediatric office. Premier also hired a pharmacist whose primary job was to enroll patients in a pharmacy partner program.
After installing Optum One, Premier found gaps in their care management program that they have since filled.
• Taking the right amount of medication at the right time. To succeed in their quality programs, Premier needed to do a better job at medication adherence. To address that need, they hired another pharmacist and had their original pharmacist use Optum One to identify high-risk patients and ensure the patients had the right prescription dose and were taking their prescriptions regularly. A comparative study within the Allegheny Health Network — Premier’s parent company — showed that more than 90 percent of patients who spoke with a Premier care management pharmacist completed a Medication Therapy Management (MTM) call in 2017, which aided improved levels of medication adherence. That percentage was far higher than for other members of the network who used an outside vendor to promote MTM calls.
“We got such great results because it was one of our pharmacists calling, who they had either spoken with previously, or who they recognized as calling from Premier,” said Holly Kern, RN, Premier’s director of quality. “Because they identified with that provider and had direct access to that provider, there was an automatic level of trust.”
• Taking care of the whole patient. An Optum One report showed Premier that their nurse navigators were focusing a significant amount of time helping patients access community resources. To keep their nurse navigators focused on clinical issues and still provide holistic care to their patients, Premier hired a social worker who helps all patients under care management address social concerns.
• Taking diabetes care to a higher level. Optum One helped Premier see that their diabetes patients needed more specialized care. To meet that need, the group hired a board-certified endocrinologist, who had his patient panel filled within three months. Optum One also showed Premier that many of their type-2 diabetes patients could benefit from prevention, so the group hired a registered dietitian/certified diabetes educator to help diabetes patients eat better and better manage their condition.
“We work really hard here,” Kern said. “Our care management team works every minute of the day to do what needs to get done. We have great results with small teams. We can be very efficient.”
Each member of their care management team interacts with patients. For example,
if a nurse finds on a weekly call that something may not be right with a patient’s medication, the nurse can directly transfer the patient to a care management pharmacist for a consultation. Pharmacists can share a task via the EHR with the patient’s physician, who can assess needs, alter the prescription, and send it to the patient’s preferred pharmacy within minutes. If the nurse navigator sees the potential for a patient to readmit, they can be directed to a social worker. Premier estimates between 50 and 60 percent of its high-risk heart failure patients have spoken with at least three members of the care management team.
Reducing readmissions, pinpointing patients in need
Perhaps the greatest success Premier has seen with Optum One is the way it has helped them reduce readmissions. Prior to 2015, nurse navigators focused their energy on identifying gaps in care for patients who had appointments to see their physicians. Manually reviewing patient charts was time consuming, but it did help the clinician identify needs around preventive care and disease management. The predictive capabilities of Optum One allowed them to change their focus. Instead of focusing on patients who are seen regularly, they can now find patients who are at risk regardless of whether they have regular visits with their physicians.
“Now we’ve truly identified those patients that are at 70 to 80 percent at risk for a readmission or an admission, and those are the patients we want to target,” Kern said.
Optum One provides hospital admission risk scores for patients with congestive heart failure, diabetes and pediatric asthma. Identified patients get a weekly outreach call from their clinic’s nurse navigator (high-risk pediatric patients get a call once a month). This call helps the nurse establish a relationship with the patient. Patients know that when they feel like they need to visit the ER or urgent care, they can call their nurse navigator who will help them self-manage and get them an appointment with their primary care physician — often within 24 hours.
When Premier began focusing on heart failure (HF), its readmission rate for HF patients was greater than 13 percent. Focusing on gaps in care for known patients helped them bring that number down to 9.5 percent in 2014. However, in 2015, the number increased to 11 percent. When Optum One gave them the information they needed to identify HF patients who were at high risk for a re-admission, they were able to better focus their efforts and cut their readmission rate to 7.9 percent in the period between June 1, 2015 and May 31, 2016 — a 27 percent improvement. They anticipate their targeted efforts will yield further improvements.
Optum One saves care management teams time and allows them to identify cohorts with pinpoint precision. For example:
• Needle in a heart failure haystack. Premier cardiologists identified a new medicine that could significantly improve management of heart failure patients. They had instructed their nurses to go through charts to find heart failure patients who have
an ejection fraction of less than 35 percent, who are on a beta blocker, who are not at atrial fibrillation and who have a heart rate that is still above 70 beats per minute. The nurses found only one patient that fit the description. Using Optum One, Premier found 60 patients within five minutes.
• Metformin not for everyone. In April 2016, the Food and Drug Administration issued a warning that diabetes patients with low kidney functions should not be taking drugs containing metformin. Care management pharmacists used Optum One to generate a comprehensive list of patients with diabetes who were also taking metformin-containing drugs. They provided the information to the patients’ prescribing physicians for outreach.
• Closing gaps on prescribing rates. As part of their Together 2 Goal efforts, they wanted to ensure that their diabetes patients were on a statin. However, some patients with diabetes were seeing a cardiologist within Premier but were seeing
a primary care physician outside of Premier to manage their diabetes. Optum One identified 250 patients who fit that criterion, giving cardiologists the ability to know who needed counsel on statin prescription choices.
Preparing to take on more risk
Providers have been required by Medicare and commercial payers to
report on quality for more than a decade. Now, they’re taking steps to pay for quality. In its continuing effort to lead their market, Premier Medical Associates has committed to moving just over half of its insured patients to risk-based contracts by mid-2017. Optum One is a big reason why Premier is confident they can be successful in this effort.
In addition to quality of care, Premier is looking for ways to reduce the cost of care for patients. Optum One can identify which physicians are utilizing more expensive medications without improving outcomes. Premier anticipates using this information to educate prescribers on their prescribing patterns. And, in preparation for its risk-bearing contracts, they are continuing their efforts to reduce hospitalizations and emergency department visits where appropriate. Premier’s proactive strategy towards population health management puts it in a strong position to succeed under risk-based reimbursement.