Integrating specialty care

Editor's note: As health systems continue to diversify across the continuum of care, healthcare leaders will need to identify which services to offer and where to offer them. A recent Modern Healthcare editorial webinar, “The Future of Specialty Service Lines in a Diversified System,” focused on that important trend and addressed a number of key questions, including: Should hospitals be bringing more services in-house? Where do specialty hospitals fit into the picture? Which strategy holds out the greatest promise of enhancing both the top and bottom lines? The webinar was hosted by Modern Healthcare reporter Beth Kutscher, and the panelists included Aaron Bujnowski, senior vice president of strategy and planning, Texas Health Resources; Robert Huckman, professor of business administration and faculty co-chair of the Harvard Business School Healthcare Initiative; and Alan Sattler, president, ProMedica Acute Care Division. What follows is an edited excerpt of the Q&A session of the webinar.

Beth Kutscher: Fifty percent of hospital admissions are now coming in through the emergency department. How will emergency medicine be affected by the integration of specialties?

Robert Huckman: I think that the key here is going to be trying to spend some time looking at the patterns of the emergency cases that come in. A lot of organizations are trying to begin to wrestle with this issue. We may very well have patterns and flows within the emergency department that begin to look in many ways like many forms of specialized care paths—and I don't want to use the term protocol because I know that often comes with judgments around it—but nonetheless, looking for a sort of pattern recognition in the types of cases that do come through ERs and beginning to think about, can we come up with mechanisms for using certain triggers and certain cases to set off a certain flow of activities? And I think a lot of that would mimic a lot of the benefits of specialization that are seen in other areas of the hospital, and certainly would help with obviously the massive coordination issues that are required for a large number of emergency patients.

The other piece that will help us is, hopefully, stronger integration of technology. So, we are seeing already that emergency radiology is quite firmly housed in emergency departments now, not so much in radiology. In many ways, you'll begin to see some of these specialties define themselves in a slightly different way because of the nature of what's coming into our hospitals and where it's coming in.

Kutscher: Mr. Sattler, how does ProMedica integrate post-acute into the acute-care hospital and physician relationship incentives for managing transitions?

Alan Sattler: Quite frankly, in the post-acute area we are looking at any metrics that we can link to that service line, and most of the focus, at least initially in the first year or so, has been around the acute-care experience. But the nice part about the service line structures that we have set up is every year we look at new metrics, and we determine if those metrics need to be changed, in partnership with our physicians. And as we establish improved performance, we are able to look at new metrics and establish those. So, I think we'll branch out and we'll look at a deeper opportunity to expand clinical excellence and probably pick up post acute as well as other areas as we continue to make sure that we have the very best clinical excellence in our acute care areas.

To date, we probably haven't done it a tremendous amount there, but the structure and the model is flexible enough and nimble enough that every year we change those metrics. And we'll expand that and develop it. And, of course, it's ever changing, right?

The metrics will change just as the demands and the requirements within the healthcare segment change. So that's the beauty of the flexibility of being able to look at those each year and set those metrics for the coming year.

Kutscher: Mr. Bujnowski, do you see any reluctance in patients in traveling to specialty care centers?

Aaron Bujnowski: We've actually taken a look at patients and patient travel times. I think it depends on the condition. We haven't seen a huge aversion to people driving for their specialty care, especially when the competency of the physician and the staff at the location is deemed to be great.

In the Dallas metroplex, when we do the analyses, we see people driving from one side of the metroplex to the other for care; although, principally, they will seek care somewhat in a geographically close area to where they live or work, and certainly we try to accommodate that. But for specialty service lines, especially at the higher-acuity levels, the travel doesn't seem to be a significant issue or barrier to them receiving care.

Kutscher: What information technology platforms exist to collect, analyze and manage population health, and how is it integrated into care management?

Sattler: I don't know if we have an overriding platform today that I could answer that question with. We use McKesson's in our clinical applications, but we are looking at, how do we do that in an IT solution for population health? And I'm not sure we have the answer to that today, but clearly it's going to be important as we go forward.

Bujnowski: At Texas Health, population health is one of our primary strategies looking forward. At our 14 wholly owned hospitals, we have Epic deployed. We've actually tried to advance our IT. Recently, we were named one of the most wired systems nationally, and for many years, we pushed forward our IT infrastructure. And so within all our hospitals, we have very good flow of information within the wholly owned hospitals. We are currently building an HIE to connect all of our physicians' clinics to our hospitals, and that will eventually extend out into the community as well. And so we're trying to advance our IT infrastructure as quickly as possible.

The three of us were speaking before the call that being able to use data to truly look at risk, and risk-stratify patients, is going to be a key to accountability, and if you take away the O in an ACO and just say accountable care, to be accountable for those patients and understand where the risk factors are and being able to address those risk factors appropriately, that healthcare information is going to be critical to all of that. And at Texas Health, we're trying to push that forward as quickly and aggressively as we can.

Sattler: I would echo that. Holistically, I think Rob talked about the holistic approach. Does that get lost in specialization? And so we use McKesson on the acute-care hospital side clinically, and then we use Allscripts in the physician group practice. But we know, ultimately, we need to have a system solution that brings both the ambulatory-outpatient physician and acute-care facilities together from an IT standpoint, and we are aggressively on that same path.

Huckman: I think as both Alan and Aaron have suggested, the challenge of just trying to coordinate all of the activities that occur from when the patient enters the acute-care or even the primary-care delivery system through when they get their acute treatment resolved is enough of an information technology problem to try to manage; but I think as Aaron hinted at, so much of the IT issue is going to also be drawing data at a much earlier point in the process, that is from the consumer and where consumer health is prior to actually interacting with the system. And I think this is the thing that makes the integration challenge even larger than the significant issue it's kind of been historically.

Sattler: I think the wonderful opportunity there is the consumer. ... Under healthcare reform, I think the consumer aspects of this are going to push our industry aggressively in that consumerism-type approach in ways that maybe we can't even think of today, but I think in the end, it's going to all be good. And if we just keep our eye on the things that matter, which is what matters to patients and to families in the broader context, then I think the industry as a whole is going to get better, and we're going to do better because of it.

Bujnowski: And I think maybe one addition to, perhaps the holy grail of it all, is to make sure that the right information is actually in the hands of the patient, because, ultimately, each one of us individually is responsible for our own health.

And to the extent we can as healthcare providers enable the consumer to understand the contributors to his or her own health, and we as providers can help facilitate interventions that help them mitigate those risks even before they express, that's where the true differentiator is in terms of a demand side kind of shift in cost as we prevent illness even before they walk into a hospital.

Kutscher: Mr. Bujnowski, have you thought about your insurance partnerships and the impact they have on this process and having a holistic approach to service-line delivery?

Bujnowski: The payers are certainly going to be the near-term and the long-term key players in the specialty service lines. We work very closely with the insurance companies and the payers to develop arrangements that would be beneficial, especially when we look at some of the value-based payments and the way we're arranging those. Texas Health recently signed on the principally primary-care side, an ACO arrangement with Aetna to look at ways that we can engage with individuals earlier in the population health realm.

Looking at specialty service lines, opportunities for bundled payments or targeted carve-outs I think will continue to be there and will be enhanced by the performance of the service line to the extent that service line is capable of providing top-tier outcomes and top-tier cost performance. The opportunities for bundled payments to deliver that value to those who are at risk, whether it be an employer or a plan, will be there even more aggressively in the future.

Follow Modern Healthcare on Twitter: @Modrnhealthcr