HFMA conference: changing physician choices to lower costs

LAS VEGAS—Modern Healthcare reporter Tara Bannow is attending the Healthcare Financial Management Association's annual conference in Las Vegas this week, an annual gathering of health system financial leaders and vendors that provide products for revenue cycle management, data analytics and other services. Here are some takeaways from presentations and meetings on Tuesday.

To lower costs, Cedars-Sinai finds physician outliers

For health systems, lowering the cost of care will require more than just reforming their operations. At Cedars-Sinai Medical Center in Los Angeles, the task involves studying the decisions doctors make.

Dr. Scott Weingarten, Cedars-Sinai's chief clinical transformation officer, told HFMA audience members that health systems overall haven't been highly successful in affecting physician decisions. That's simply because it's hard to get doctors to change, especially since many of them work in private practices and aren't employed by systems, he said.

"A lot of the things we've been working on for operational efficiency are very, very important, but we're unlikely to significantly bend the cost curve if we don't focus on physician decisions," Weingarten said.

Part of that change involves reducing the amount of low-value care provided to low-risk patients. Using Kaiser Permanente as an example, Weingarten said the health system determined that its physicians were ordering too many Vitamin D tests, so they removed them from the preference lists in their electronic health record. After that, the number of such screenings decreased from 74 tests per 1,000 patients to 24 per 1,000 patients, he said.

"They started making it harder to do the wrong thing and making it easier to do the right thing," he said.

By plugging similar changes into its own EHR, Cedars-Sinai has identified outlier physicians who tend to administer high levels of low-value care. In one example, a single physician out of 47 doctors studied accounted for 62% of the potentially inappropriate pap smears identified. Cedars-Sinai also identified one physician who ordered six Lyme disease tests over a three-day period in 2014, even though the disease is extremely rare in Los Angeles County, Weingarten said.

"If you provide this type of information, there's an opportunity to improve care," he said.

Using data to tackle high implant costs

At Providence St. Joseph Health, lowering the cost of care means having tough conversations with physicians about which implants they use in hip and knee replacements. Prices for the devices can vary widely.

Kevin Fleming, vice president of orthopedics and sports medicine at the Renton, Wash.-based system, told Modern Healthcare that when implant contracts come up for renewal, his team gives doctors data showing which products have the best outcomes across a broader population of patients than just their own.

"We want to give physicians choices but also be sustainable with a nonprofit mission, focused on the poor and vulnerable within our communities," he said. "The economics just don't allow the high prices of the past."

That message tends to get a better reception when it comes from fellow surgeons, Fleming said.

"Me coming from the system office to say, 'Gosh, your costs are really high. Here's some other folks whose costs aren't as high,'" he said. "It's different when a peer comes in and says, 'I'm taking care of similar patients. Here are some of my approaches. Here are the outcomes I'm getting.'"

That's one of the functions of Providence St. Joseph Health's Orthopedics and Sports Medicine Institute. The institute's main purpose is to share which practices work well across the 50-hospital health system, despite geographic variations.

"We've tried to bring people together to really find those approaches, tactics, care pathways and ways to connect with patients that are delivering the best outcome," he said.

Louisiana clinic partners with the Blues to improve care

Mistrust and strained relationships are common among providers and insurers, but one duo in Louisiana proves that's not always the case.

Blue Cross and Blue Shield of Louisiana and the Baton Rouge Clinic, a multispecialty practice that serves more than 250,000 patients, in 2014 entered into what the insurer calls a quality blue value partnership, an accountable care organization program that aims to improve outcomes for defined patient populations. Natalie McCall, accountable care organization program director for the Louisiana Blues, and Shunn Phillips, the clinic's chief financial officer, shared the results of their partnership with HFMA conference attendees.

Under the program, the health plan deployed its quality navigators, liaisons who work with primary-care practices, to review patients' records and identify gaps in care. A team of analysts spent significant time in meetings with clinic executives to prepare a customized data analysis, allowing them to address questions and concerns. A separate team focused solely on population health improvement, working side-by-side with providers on targeted interventions.

Phillips said her clinic has limited resources on a given day, and the partnership required a significant time commitment. However, it was worth it once she learned the high volume of data the insurer had on her patients, including the surprisingly high amount of care they accessed outside of her practice.

Data is one thing, but it takes provider engagement to turn that into positive change, she said.

"They've got a lot of data, they've got a lot of numbers, but we were able to turn it into actionable information," Phillips said.

The results, profiled in a 3M report, included a 3.7% increase in pharmacy costs at the clinic between the program's first and second year, compared with 12.3% among peer physicians. Providers in the program also increased the proportion of their patients whose chronic conditions were successfully managed.

At the system level, the program involved using data from the Blues to create hard stops in the clinic's EHR to alert clinicians about expensive drugs that have cheaper alternatives. The clinic also offers same-day appointments to reduce preventable emergency room visits.

At the individual level, the clinic embeds care transition nurses in hospitals where its patients are admitted. The nurses notify physicians when they're admitted and schedule follow-up visits before they're discharged.

The ultimate goal is to use data to predict patients' future needs and risks and intervene ahead of time, Phillips said.

Phillips and McCall described a significant amount of relationship-building that had to happen for the partnership to work.

"This wouldn't work if we didn't trust the data," Phillips said.