Innovations: Evolent helps with high-risk patients

It's pretty well understood now that a small subset of patients drives most of the costs in healthcare. But on any given day, physicians aren't necessarily using their time to focus on these individuals.

That's a workflow issue. But in the world of risk-based payment models, physicians will be key to intervening with high-risk patients and keeping them healthy.

In 2011, executives from the Advisory Board Co., including former CEO Frank Williams, spun out a company called Evolent Health from the consulting giant. They partnered with Pittsburgh-based health system UPMC, which like a growing number of health systems, operates as both a provider and a health plan.

UPMC had developed a technology platform known as Identifi that can analyze data from disparate sources, such as insurance claims or electronic health records and create care-management plans.

Evolent's platform aims to not only pinpoint high-risk patients, but find ways to change their behavior. A lot of that work comes from focusing on and motivating physicians.

That makes the company different from other software companies trying to help providers operate in a risk-based environment. “It was developed by a provider in a real-world setting,” Williams said at the company's San Francisco office. “We wanted to stay true to our provider philosophy … and we believe in a provider-driven model.”

The Identifi platform allows users to set the parameters for determining who falls into the specific high-risk populations they want to target. For instance, they could tell the software that they want to focus on the “18 club”—patients with nine different doctors on nine or more medications.

The platform then singles out action items (such as making sure patients know how to use their medication) and potential problems (such as flagging patients who are smokers). “You need to be able to stratify the patient population to know where to take action first,” said Chad Pomeroy, Evolent Health's chief technology officer.

The next step is to work with physicians on care-management plans. If a home visit is recommended, for instance, the technology platform can track whether it occurred. It also can identify when clinicians veer from certain protocols.

“There are analytics everywhere, but analytics don't do any good if they're only retrospective,” Williams said.

The consulting piece allows Evolent to suggest creative care practices, such as having physicians set aside a couple of days each week for more complex visits. On those days, they can have a care manager work with high-need patients. Evolent also will train the care managers who work onsite.

“A lot of it is a very basic thing where you're involving physicians in a way that they haven't been involved before,” Williams said. “And it's magic.”

Indiana University Health began working with Evolent Health to manage high-risk populations in its employee health plan, Medicare Advantage plan and commercial insurance products—a total of 200,000 lives.

“We had made a big investment in our EHR,” said Ryan Kitchell, chief administrative officer at IU Health. “We wanted to leverage that investment and all that great clinical information we were collecting.”

The system used Evolent's platform to stratify patients into groups that could be actively managed. For instance, physicians could reach out to patients who weren't coming in for regular appointments or who weren't complying with treatment regimens.

IU Health also has another 50,000 people covered under its Medicare Shared Savings accountable care organization. Since it is not using Evolent's tool for that group, its ACO program has served as a sort of control group for assessing outcomes in seniors. “We've definitely gotten better results (in the Medicare Advantage group) as it relates to 30-day readmissions, overall cost trend and utilization days per 1,000,” Kitchell said.

Evolent's business model is primarily fee-based, but it does take some financial risk for outcomes. The company, which went public in 2015, had 1.1 million lives on its platform as of February. It reported $163.5 million in adjusted revenue for 2015, a 62.1% increase year over year, though the company is still operating in the red.

While a select group of health systems have taken the plunge into full risk, the majority of providers are still taking small, calculated steps, Williams noted.

“It's a scary leap for a lot of health systems looking to transform,” he said. “In a lot of ways, Evolent was built to provide the tools.”