A conversation with Farzad Mostashari MD

I participated in a webinar with Farzad Mostashari MD, scM, former director of the ONC (Office of the National Coordinator for Health IT)  sponsored by the data analytics firm Wellcentive   He is now a visiting fellow at the Brookings Institution.  Farzad spoke on points made in a recent article in the American Journal of Accountable Care, Four Key Competencies for Physician-led Accountable Care Organizations.  

The hour-and-a-half format lent itself well to a Q&A format, and basically turned into a small group consulting session with this very knowledgeable policy leader!  

1.  Risk Stratification.  Begin using the EHR data by ‘hot spotting.’  Hot spotting refers to a technique of identifying outliers in medical care and evaluating these outliers to find out why they are consuming resources significantly beyond that of the average.  The Oliver Wyman folks wrote a great white paper that references Dr. Jeffrey Brenner of the Camden Coalition who identified the 1% of Medicaid patients responsible for 30% of the city’s medical costs.  Farzad suggests that data mining should go further and “identify populations of ‘susceptibles’ with patterns of behavior that indicate impending clinical decomposition & lack of resilience.”   He further suggests that we go beyond a insurance-like “risk score” to understand how and why these patients fail, and then apply targeted interventions to prevent susceptibles from failing and over utilizing healthcare resources in the process.  My takeaway from this is in the transition from volume to value, bundled payments and ACO style payments will incentivize physicians to share and manage this risk, transferring a role onto them traditionally filled only by insurers.

2.  Network Management.  Data mining the EHR enables organizations to look at provider and resource utilization within a network.  (c.f. the recent Medicare physician payments data release).  By analyzing this data, referral management can be performed.   By sending patients specifically to those providers who have the best outcomes / lowest costs for that disease, the ACO or insurer can meet shared savings goals.  This would help to also prevent over-utilization – by changing existing referral patterns and excluding those providers who always choose the highest-cost option for care (c.f. the recent medicare payment data for ophthalmologists performing intraocular drug injections – wide variation in costs).  This IS happening – Aetna’s CEO Mark Bertolini, said so specifically during his HIMSS 2014 keynote.   To my understanding, network analysis is mathematically difficult (think eigenfunctions, eigenvalues, and linear algebra) – but that won’t stop a determined implementer from it (it didn’t stop Facebook, Google, or Twitter).  Also included in this topic was workflow management, which is sorely broken in current EHR implementations, clinical decision support tools (like ACRSelect), and traditional six sigma process analytics.

3.  ADT Management.  This was something new.  Using the admission/discharge/transfer data from the HL7 data feed, you could ‘push’ that data to regional health systems.  It achieves a useful degree of data exchange not currently present without a regional data exchange.   Patients who bounce from one ER to the next could be identified this way.  Its also useful to push to the primary care doctors (PCP) managing those patients.  Today, where PCP’s function almost exclusively on an outpatient basis and hospitalists manage the patient while in the hospital, the PCP often doesn’t know about a patient’s hospitalization until they present to the office.  Follow-up care in the first week after hospitalization may help to prevent readmissions. According to Farzad, there is a financial incentive to do so – a discharge alert can enable a primary care practice to ensure that every discharged patient has a telephone follow-up within 48 hours and an office visit within 7 days which would qualify for a $250 “transition in care” payment from Medicare.  (aside – I wasn’t aware of this. I’m not a PCP, and I would carefully check medicare billing criteria closely for eligibility conditions before implementing, as consequences could be severe.  Don’t just take my word for it, as I may be misquoting/misunderstanding and medicare billers are ultimately responsible for what they bill for.  This may be limited to ACO’s.  Due your own due diligence)

4.  Patient outreach and engagement.  One business point is that for the ACO to profit, patients must be retained.  Patient satisfaction may be as important to the business model as the interventions the ACO is performing, particularly as the ACO model suggests a shift to up-front costs and back-end recovery through shared savings.  If you as an ACO invest in a patient, to only lose that patient to a competing ACO, you will let your competitor have the benefit of those improvements in care and eat those sunk costs!  To maintain patient satisfaction and engagement, behavioral economics (think Cass Sunstein’s Nudges.gov  paper), gamification (Jane McGonigal ), A/B Testing (Tim Ferriss) marketing techniques.  Basically, we’re applying customer-centric marketing to healthcare, with not only the total lifetime revenue of the patient considered, but also the total lifetime cost!

It was a very worthwhile discussion and thanks to Wellcentive for hosting it!