BY: JASON DINGER
Mark Pernice
MissionPoint Health Partners is a strategic venture into population health with Saint Thomas Health, an Ascension ministry in Nashville, Tennessee. The partnership began in 2012 by serving commercial self-funded and Medicare fee-for-service populations. It has since expanded to nearly all populations in the health care system, including individuals covered through Medicaid and the federal marketplace. MissionPoint recently became a direct subsidiary of Ascension.
Work in health care remains very complex. It takes innovation and continuous, rapid learning in order to ensure success over different geographies, populations and disease states such as diabetes, chronic heart failure and other chronic conditions. That means failures must come quickly and often, in order to lay aside what doesn't work and ensure that the successful innovations are scaled quickly.
Of the many lessons MissionPoint has learned during the last three years, the most important was to stay curious and listen deeply for what resonates with members and providers.
FOUR AIMS
MissionPoint's population health management approach applies to communities, hospitals, physicians and patients. It identifies four aims: Improve the health status of the community; lower health care costs; enrich physicians' quality of life; and improve the patient experience.
Its "health partners" concept is the cornerstone of MissionPoint success. The health partners provide services across the continuum of care using a whole-person approach to assess MissionPoint members' physical, mental and emotional needs. The team includes clinical nurses with experience in all medical specialties and nonclinical professionals with experience in social work, counseling and health coaching. They connect with patients through diverse avenues: referral by their primary care physician, a hospital admission, an emergency department visit or self-referral.
The health partners coordinate patient care with physicians and other clinicians. They help MissionPoint members navigate the health care system, identify and remove barriers that keep patients from caring for themselves and solve other complex nonclinical challenges — many that providers or payers don't address or may not know about.
Health partners use a set of evidence-based assessments and clinical-care paths to structure interactions with patients. They become a patient's advocate and, as such, can spend time getting to know him or her and working to solve obstacles that prevent the patient from returning to his or her previous state of health — or achieving a better one.
By meeting with members during hospital discharge or by making home visits, health partners may learn an elderly patient's home lacks proper heating or cooling, or that he or she isn't eating healthfully or has transportation problems that result in missed medical appointments. A health partner might arrange to have a furnace repaired, or work with nonprofit organizations and churches in the community to secure free or reduced-cost transportation and nutritional support.
One health partner learned that a member with diabetes was forgoing medication in order to pay for the needs of a 4-year-old child for whom she recently received guardianship. The health partner was able to arrange for the patient to receive the insulin she needed.
However, overseeing expanded social services for patients is only part of MissionPoint's work. More than 7,000 providers currently in the MissionPoint network serve more than 250,000 members in seven states. MissionPoint works with a number of different types of populations, that is, groups of people who receive health benefits through their employer or from government programs like Medicaid and Medicare. The organization's efforts are creating cost savings across every population; MissionPoint is among the 25 percent of accountable care organizations in the Medicare Shared Savings Program that met savings targets set by the Centers for Medicare and Medicaid.
DATA AND DIAGNOSIS
Before MissionPoint served its first member in 2012, leadership conducted more than 250 interviews with physicians, patients, employers and payers in order to understand the health care system obstacles that so many faced.
That research revealed that primary care physicians favored capitation — payments received per member, per month, even if they do not see the member. Such guaranteed monthly payments even out a physician's cash flow and allow him or her to meet productivity and financial goals without overscheduling. However, under the capitation model, physicians are required to meet a set of quality metrics, including seeing a patient within 48 hours of a request.
Patient data revealed that many nonclinical indicators — access to transportation, food insecurity or use of a footstool to get in and out of bed — strongly predicted health care costs and, as many hospitals know, a small percentage of patients account for a high percentage of cost. The data show 5 percent of MissionPoint members incur 50 to 70 cents of each dollar in health care spending managed by the organization.
Employers attempting to better manage health care spending found that the companies managing employee health care claims — third-party payment administrators — provided large amounts of data about how an employer's health care dollars were being spent, but very little analysis. The quality and quantity of data often depended on the size of the employer and the company doing the payment administration. The information didn't assist employers with any steps to improve care for employees or to reduce costs. Employers also stated that they lacked the resources to effectively intervene with employees' health care challenges.
FROM ANALYSIS TO ACTION
MissionPoint uses a host of software systems and data analytic functions to support the health partners as they work with members. MissionPoint's care management system analyzes vast amounts of data and helps MissionPoint identify members who need the most help and support. The care management system also generates customizable care paths that help the health partners as they assist patients with specific needs.
Extensive analytic capabilities allow MissionPoint to react to needs as they arise, as well as to proactively engage populations even before events occur. For instance, if the system notices that a patient repeatedly goes to the emergency department because of asthma, it notifies a health partner who then can meet with the patient to identify and address factors that might be causing the breathing problem. The patient could be having difficulty using his or her inhaler properly, the dosage of medication might need adjusting, prescriptions might be going unfilled, or such asthma triggers as excessive dust or animal hair might be in the patient's environment.
MissionPoint's systems also review data from a variety of sources and generate a risk score for each member. If the score is high, health partners proactively reach out to members to ensure they have the support and resources they need to avoid a potentially serious health event like a heart attack, stroke or relapse of a chronic condition. As health partners work with patients, they add observations and other data — administrative, demographic, environmental and behavioral — to a member's profile.
Real-time data from network facilities allow health partners to view information on hospital admissions, discharges and emergency visits to help manage transitions of care and assess problems. Historical and ongoing claims data provide an additional population risk management tool and help to evaluate any correlation of a patient's condition to the results of similar patient populations. MissionPoint's analytics also provide data about a member's health status that can be shared to help providers improve their engagement with patients.
COMMUNITY HEALTH
The MissionPoint model grew from listening to providers, engaging patients and aggregating as much data as possible. The findings led to a three-pronged approach.
First, creation of a provider network focuses on a patient-centered medical home model for primary care. For providers within the network, MissionPoint developed a unique reimbursement system that aligns the financial incentives of the provider, the patient and the payer across the health care spectrum. Providers receive incentives to better coordinate care, improve health outcomes and lower the overall cost of care.
Second, creation of a clinical management team helped support the network. Health partners assisted patients in navigating the health care system and managing a range of health and nonclinical needs. A diverse set of strategies and technologies helped coordinate care focused on the patient's overall health and wellness.
Third, a diverse set of technologies and data support all operations. By compiling and analyzing claims data and clinical and nonclinical records, MissionPoint tracks, segments, analyzes and executes care plans based on historical and real-time data to manage both the provider network and member populations.
LOWERING COSTS
Key performance indicators in the patient population with self-insured employers included a reduction in 30-day hospital readmissions from 11 percent to 6 percent during the program's first three years. Emergency department visits declined 27 percent and adoption of generic pharmaceuticals increased 19 percent during the same period. During the third quarter of 2013, MissionPoint's average Medicare Share Savings Program expenditure per member was nearly 5 percent lower ($9,298) than the expenditure of other ACOs ($9,774) in the country.
MissionPoint continually reviews its data against national benchmarks on various disease states, such as diabetes, asthma, arthritis or other chronic conditions. One review found a decrease in a company's pharmaceutical claims for asthma patients, but utilization of emergency department visits were 300 percent higher than for a comparable group of asthma patients. Health partners discovered many of these members weren't using spacers on their inhalers. A spacer is a plastic tube that improves the way an inhaler administers medicine. They are sold separately, and some can be relatively expensive. MissionPoint shared the discovery with the employer, who changed its employees' health care benefits to offer coverage for spacers. Emergency department visits — averaging a cost of $600 per visit — dropped to almost zero for this group.
ENRICHING PHYSICIANS' LIVES
The health care environment is continually pressuring physicians from almost every angle, and models are still evolving for how providers are paid for care.
MissionPoint negotiates competitive rates and fee schedules with providers and includes the opportunity for providers to receive a portion of savings generated when a specific population's total cost of care comes down. MissionPoint annually distributes any "shared-savings" payments to providers based on the number of members treated and the providers' performance on MissionPoint-designed quality measures. As reimbursements continue to decline and change across the nation, shared savings increasingly will become a new revenue stream for many providers engaged in population health efforts.
MissionPoint's payment structure thus gives providers financial incentive to better coordinate the overall care needs of a patient. If the annual cost of claims is beneath a predetermined benchmark, the employer retains 25 percent of the savings. If providers meet quality metrics, MissionPoint distributes a majority of savings back into the network of primary care providers, specialists, hospital-based physicians, outpatient facilities, inpatient facilities and various ancillary and post-acute providers. Providers can earn additional shared savings payments for meeting patient access metrics, such as offering weekend hours, after-hours clinics and secure emailing of patients.
CONCLUSION
Though MissionPoint didn't expect to generate savings of any real significance until the second or third year after launch, staying nimble and making many system improvements led to significant savings in its first year. What's more, as MissionPoint expanded from one market in 2013 to seven in 2015, most challenges proved to be the same across the country.
Surveys have revealed high levels of MissionPoint members' satisfaction with their health partners. Ninety-seven percent of members said they were satisfied or very satisfied with information their health partners provided regarding their specific situation and the level of assistance the members received to enable self-care.
Managing population health requires MissionPoint to be flexible and adaptive to serve many segments of the population and to move from managed care of specific diseases to caring for persons in a holistic way. To receive the best care, patients must receive services across the continuum at the time those services are needed. Success is achieved when all stakeholders work together to remove barriers encountered while patients return to health, independence and self-sufficiency.
JASON DINGER is CEO of MissionPoint Health Partners, Nashville, Tennessee.