In L.A. County, 38% of the population is covered under Medi-Cal, California's version of Medicaid. Clinicians in the L.A. County safety net are stretched to capacity, and the state's population continues to swell. Safety net practices in particular tend to be reactive and fragmented environments where population health management is minimal.
That's according to Cathy Mechsner, manager of HIT programs at L.A. Care Health Plan, the largest public health insurance company in the U.S., serving 2.2 million members in L.A. County.
In a HIMSS20 Digital presentation, Mechsner and Dr. Raj Lakhanpal, founder and CEO of Spectramedix, said that ensuring Medi-Cal patients in L.A. County receive the care they need has become extremely difficult, necessitating an increase in the use of evidence-based tools and data as part of the Centers for Medicare and Medicaid Services' Transforming Clinical Practice Initiative.
TCPI is a $700 million, four-year, data-driven national quality-improvement program with the goal of driving Medicare and Medicaid practices toward value-based payment models, which emphasizes reimbursement based on quality measures, health outcomes and clinical quality.
About five years ago, L.A. Care was awarded a $16 million grant to implement TCPI, and this resulted in the creation of the Los Angeles Practice Transformation Network (LAPTN), whose goals were many: to increase providers' use of data to drive population health management; to optimize workflow processes and improve outcome measures; to reduce inpatient utilization; and to generate cost savings.
So far, LAPTN has helped its clinicians produce tens of millions of dollars in cost savings and met numerous quality-improvement targets.
The network looked at the areas of greatest concern in L.A. County and honed in on diabetes and depression as the major disease states worthy of immediate attention. From that determination, LAPTN honed its mission on increasing diabetes management, child depression screening, and adult suicide risk-assessment, with specific percentage-point benchmarks set for each goal.
Since TCPI is a data-driven quality-improvement program, technology was needed to address the collection of disparate data sources, the analysis of the data and the means by which data was reported to CMS – and importantly, to providers.
Noble goals, but according to Lakhanpal, there were challenges in implementation.
"These were safety net providers," he said. "There were about 3,200 clinicians, and they had disparate EHR systems. Of the multiple practices there were two or three large practices, but many smaller practices … which means their ability to have technology support was minimal. This was a large volume of data as well. The implication of smaller practices is they're not mature in their EHR adoption. Their processes are also not mature, so there are challenges with missing data, incorrectly mapped data and the data being available at all."
L.A. Care needed a platform for LAPTN to validate and access data and, more importantly, share that data with clinicians in a manner that allowed them to improve their care quality. Spectramedix stepped into the breach with the PHQ-9 tool.
PHQ-9 was administered multiple times a year for patients presenting with depression. Using deeper one-on-one support than the TCPI program offered on its own, with ongoing measurement and analysis of the data, both the coach and clinician team could see improvements as well as gaps in the workflow processes that were implemented.
"That really was very key in enabling the coach to customize workflow processes and interventions," said Mechsner.
The program began in 2015. By the third year of implementation, it had achieved $136 million in savings and met or came close to meeting benchmarks in diabetes and body mass index, as well as others.
Now, population health is managed in a patient-centered way with an interdisciplinary, team-based approach. Community partners are helping to close the loop of referrals and follow-ups, with a focus on social determinants of health, and the quality of patient data in the EHR has been improved dramatically.
Perhaps most importantly, the program has created a lasting culture of data-driven quality improvement, which will be key to achieving value-based care in L.A. County.
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