Episode 9 - How We Did
The MaineHealth Accountable Care Organization works with providers to improve the quality and lower the cost of care. So, what kind of success did providers and the ACO see in 2019? Julie and Mike discuss. Also, Amanda Powell, MD applies shared decision making to increasing colorectal cancer screening among diverse patients and Sarah Shepherd, MD compares her roles as ED clinician and improv actor.
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The ACO’s performance in 2019: newsletter article
Colorectal cancer screening project: poster
Foundational Medical Assistant trainings: info and registration
Advanced Medical Assistant trainings: info and registration
Project ECHO trainings
Dartmouth Co-op meeting info
Julie: [00:00:06] This is BACON, Brief ACO News from the MaineHealth Accountable Care Organization. A slow roasted monthly podcast for health care providers. I'm Julie Grosvenor.
Mike: [00:00:15] And I'm Mike Clark. Julie and I are practicing physicians and liaisons with the Maine Health ACO.
Julie: [00:00:20] In this episode, we learn how one practice is using shared decision making to overcome cultural barriers. And we talk with an E.D. doc exploring her dramatic side.
Mike: [00:00:29] Yeah, but first, get out your fork so we can dig in to this month's Meaty Topic.
MEATY TOPIC: 2019 PERFORMANCE
Julie: [00:00:38] We're dedicating this month's Meaty Topic to reviewing our recent accomplishments. And by us, I mean all the care teams that see the thousands of patients covered by the ACO's contracts.
Mike: [00:00:48] Yeah, we know that the ACO asks a lot of practices and providers, like reporting on the tons of data and focusing on the 10 major quality targets each year. So we want to look back and see what the results of our work have been, over the year 2019 and the last couple of years. Julie and I think you'll be pretty impressed with yourselves.
Julie: [00:01:09] That's right. And as you may recall from previous episodes, the basic goal of the ACO is to work with providers to improve quality of care while controlling cost and low-value utilization. The ACO assesses quality using measures related to chronic disease management and preventive care. And then the ACO asks us as providers to focus in on 10 of those measures - the Quality Top 10 that appear in the heat map which you see every month or should be seeing every month.
Mike: [00:01:40] Right. If you're paying attention. So since we're recording this episode early in December, we don't have all of the quality results for the year, but we have almost all of them. And it's clear from those data that providers will achieve the quality targets for seven measures out of the top 10. That's pretty good. That's really good, especially since targets sometimes have to reset each year and becoming more and more challenging or challenging us to reach a higher level each year or new ones appear. The biggest quality improvement we saw this year was in the breast cancer screening rate, which went up 4 percent.
Julie: [00:02:12] Well, that's great. And that one hits pretty close to home for me. But what's even better is our quality performance over a longer period of time. So if you look since 2015, we have achieved a 9 percent increase in hypertension control, a 15 percent increase in depression screening and a 16 percent increase in colon cancer screening. So that seems really impressive to me. But Mike, you're a PCP. Does this stuff matter?
Mike: [00:02:39] Well, that's a great question. I think a lot of times we do wonder if all of these efforts really matter. And, you know, our CMO, Rob Chamberlin, calculated the effect that our improved quality is having on patient mortality using published number-needed-to-treat or number-needed-to-screen data. His research shows that next year, because of our quality improvements, it's estimated that 32 fewer of our patients will die from a hypertension related cardiovascular event, 16 fewer will die from colon cancer, and two fewer will die from breast cancer. I think those numbers help to show that quality improvement isn't just an academic exercise. It really does have a real impact on patient outcomes.
Julie: [00:03:22] And that's just mortality. The morbidity numbers are even bigger.
Mike: [00:03:25] That's right.
Julie: [00:03:27] So quality's great. Now, let's take a look at how we did controlling costs and utilization. It takes a long time for claims to roll in and to get final spending numbers. So the most current ones that we actually have are from 2018. But that said, the ACO estimates that we saved around eight million dollars total in our best performing contracts. And a portion of that money comes back to us as shared savings. We earned about 20 percent more shared savings in 2018 over 2017. Now, that's great news for providers because the ACO distributes a portion of that shared savings back to the organizations to help fund quality improvement, population health projects. This is just really great recognition for all the hard work that providers are out there doing on behalf of their patients.
Mike: [00:04:16] That's right. And related to costs, there is the issue that we've been working so hard on of avoidable utilization. In 2019, the ACO did a lot of work around this and as you remember that the most visible part was the Where to Go for Care infographic that we presented on a previous podcast that was designed to help patients decide where an alternative to the emergency room would would be a good choice. And we worked also behind the scenes on reducing readmissions and avoidable admissions. Now, as these efforts all mature, the ACO will be probing that data for insights into their effectiveness.
Julie: [00:04:53] That's right. And don't forget our work on improving clinical documentation. So, remember that training we've been urging you to take all year? You did get that done, right? Right. Did you? Yeah. So our current data show that there is an improvement in documentation quality already, which is great. That means that we are justifying the expense and risks of care for our patients very well. So we have to wait until next year for final results of 2019, but that will come.
Mike: [00:05:24] So to wrap up, I think the big takeaway on performance is that change really is happening and that change is incremental. We're seeing the ACO generate significant savings across multiple contracts while still continuing to see excellent improvements in quality over time.
Julie: [00:05:41] That's right. And a lot of that success is due to the care teams and providers listening to this podcast. And thank you. Thank you to all of you out there who've done what you have to improve quality control cost and improve patient experience. We are in good shape for continued improvement in 2020. So we'll do like Curtis Mayfield says and "keep on keeping on."
Mike: [00:06:03] So for more information on the ACO's 2019 performance. Please see the bonus content for this episode at MaineHealthACO.org/BACON.
THE SIZZLE: AMANDA POWELL & COLON CANCER SCREENING
Mike: [00:06:18] Welcome to The Sizzle, our celebration of provider successes. This month, our producer Paul Santomenna talks to Amanda Powell about using shared decision making with culturally diverse patients.
Paul: [00:06:29] So, Amanda, you see patients at the pediatric and internal medicine clinic that MMP runs at the Maine Medical Center. So that practice has very diverse patients. Can you describe the range of patients that you see?
Amanda: [00:06:44] The vast majority of our patients are MaineCare patients or receiving free care through the hospital. And the bulk of those are international patients. So people coming from pretty much all over the world, everything from the Middle East, Africa to Central and South America, Vietnam, Cambodia. So we represent quite a lot of countries in our patient population. Many of them are not English speaking. So we function with interpreters quite frequently. So the goal of our project was to try to increase our colorectal cancer screening rates. And it was an area that we had identified as a problem; just generally lower rates than the rest of main medical partners, primary care. And, you know, there's lots of reasons for that, I think. But one of the big barriers that we thought was probably just the nature of our patient population for a lot of reasons. So our patients have pretty low resources and a lot of them have never even heard of the idea of cancer screenings or preventative medicine. And they're really new to that concept. So we thought by tackling this mostly using OpEx's KPI framework it would be a way to sort of systematically try to bring this to the forefront, work on our rates and try to increase them. The project evolved over quite a long period of time. So we had started with a KPI just trying to offer eligible patients colorectal cancer screening at every visit. Colorectal cancer screening, there's a few different options for it, and we were finding that even patients that consented to a colonoscopy were not completing them. So, as we delved into the colonoscopy barriers, we started to realize that FIT testing, which is a stool test for blood which is an annual test that people can do at home, was a much cheaper and lower barrier intervention or screening method that we could potentially use. Not everybody is a good candidate for that kind of test. But we started trying to focus on the people that were and putting more energy behind trying to not only offer those tests and explain why we were doing them, but then also trying to get them back. So once you hand them out to people, getting them returned to the laboratory, it can be challenging. People take the kit, they don't return it. So that was kind of where we put our biggest effort. And what the poster that we created for this project was ultimately about was the FIT return rates. And I think that's where the shared decision making piece kind of came into play, was trying to really convince people and explain to them why we cared about colon cancer screening and why this particular test was a good idea for them to return. So we ultimately ended up sort of leveraging our front office staff. The clinic is a relatively small clinic, about 2000 patients, about half of those are kids. So we're not talking about a huge number of patients. And most of them are really familiar with the staff in our office. They've developed relationships with them over long periods of time. So we started actually utilizing the PSRs or the front office staff to call people after we'd given them the FIT kits and two weeks after and remind them to return them. And we actually found that that made a pretty big difference in increasing the rates of return. And we think partially because they knew the patient, the people that were calling them, they had a relationship with the front office people already. So it wasn't just a random person calling them.
Paul: [00:10:18] Right. Right. And so what what were the results at the end?
Amanda: [00:10:25] So we actually were able to show that we could get our return rates up to almost 75 some months, as much as 100 percent of kits that were given out were returned within 30 days, which is pretty amazing if you compare that to the rest of main medical partners, primary care. The average is about 50 percent. And that's pretty good actually itself. So that's cost effective. I mean, they're not wasting the kids. And also, those people are actually getting screened. So just that little intervention of having that phone call was enough to really increase the rates, utilizing the front office staff to try to close some of those care gaps. I think is what was kind of novel about the work that we did and why the people at IHI were interested in the poster. There's a lot of effort these days to involve the entire office staff in someone's care. And I think it was a big lift for the front office staff and made them feel better about their jobs in general. You know, it can get pretty boring just checking in patients, checking out patients all day long. And I think a lot of them really enjoyed the work of actually calling patients and being involved in some of their clinical care.
Julie: [00:11:33] Do you have a provider success that others might learn from? Please e-mail us at BACON@mmc.org. No, seriously. Please. Please do. Please do. Thanks. Coming up soon, our interview with a thespian physician. You're going to want to stick around. She's a firecracker. But now our breakfast buffet where we offer you a tempting display of nourishing events coming up soon.
Mike: [00:11:55] You may not know that the ACO and MaineHealth offer free trainings for medical assistants throughout the year. The two day foundational training covers patient visit planning, taking accurate blood pressures, general communication skills and more. The one day advanced training gets into population health management, interacting with patients with opioid use disorder and other topics. The next foundational training is February 5th and 6th, and the next advanced training is February 19th.
Julie: [00:12:23] MaineHealth has at least eight Project Echo Sessions coming up in January as well. These are web based interactive videos sessions that connect primary care providers with a specialist who's an expert on a specific clinical topic. This month's topics include palliative care, breast cancer, genetic counseling, management of ADHD and anxiety in pediatric patients and more.
Mike: [00:12:46] That's right. And the Dartmouth Co-op's 40th annual practice based research network meeting is happening on January 24th and 25th in North Conway. It's a chance for primary care providers to extend their network, explore current and controversial health care topics (that sounds like fun) and expand their skill set. Providers from across northern New England are welcome.
Julie: [00:13:08] Yeah, they could improve their skiing skill set as well.
Mike: [00:13:11] Right. That seems good and less controversial, maybe.
Julie: [00:13:14] Details and registration info for all of these events and more are available as part of this episode's bonus content on the BACON website. So visit MaineHealthACO.org/BACON and go to the episodes page.
CHEWING THE FAT: SARAH SHEPHERD & ACTING
Mike: [00:13:34] For Chewing the Fat this month, our producer Paul Santomenna talks with Sarah Shepherd, emergency department physician at Southern Maine Health Care.
Paul: [00:13:43] So, Sarah, how did you get into this whole acting thing?
Sarah: [00:13:47] After medical school residency, during my fellowship, I decided to sign up for an acting class. And I took this class every Monday and I would call it Mommy Mondays because that was my time to grow as a person. And then I decided if I was going to put something in my head, it probably should be the material for my board exams and not a script. And then I was reintroduced to acting several months ago by a colleague, Dr. Howard Cohen, and he's the person who inspired me to re-engage in that aspect. So especially in emergency medicine, in the classes that I am focused on, improv, things come into the emergency department. And you have to do things on the fly. And that's what improv is. And so I certainly think that they overlap. I feel like I'm on the stage every shift. You know, I walk into a room and not only do I have the patient, but sometimes I have, you know, a gillion family members that I have to talk to and I have to build instant rapport with. So that in and of itself is a little mini stage. And the thing about improv is, you know, somebody. I don't know. I don't know if I want to phrase this right, but somebody is not going to get hurt if you mess up.
Paul: [00:15:24] Right. Yeah, the stakes are not quite so high.
Sarah: [00:15:26] Yeah. Yeah. And it's really great to just let go not be judged and have fun. That's what it is, it's playing it's adult play.
Paul: [00:15:40] OK, so this is definitely a creative outlet for you.
Sarah: [00:15:44] It is. You know, and I never thought of myself as a creative person. Science, you know, growing up, science was my jam. I remember in sixth grade. Loving, loving my biology class. And you know what, medicine is artistic. I don't think we appreciate that enough. I think that's why, you know, the saying is, you know, it's the art of medicine. We learn fundamentals and advanced concepts, but fine tuning that and having that humanistic part of our career is artistic. I don't think we understand slash appreciate that. So I jokingly say I don't think I am an artist, but I, you know, kind of talking through this, I think we all are.
Julie: [00:16:40] Do you know a colleague with an interesting experience, talent or story to share?
Mike: [00:16:48] Julie, what's with the weird accent?
Julie: [00:16:49] Haha! I was acting! Jon Lovett. Anyone? Anyone?
Mike: [00:16:55] I'll go Google that later.
Julie: [00:16:57] OK. Well, anyway, if you know a master thespian or anyone else with an interesting story to share, please email us at BACON@mmc.org.
Mike: [00:17:08] Thanks for listening. Find information related to this episode at our podcast webpage, MaineHealthACO.org/BACON.
Julie: [00:17:16] And if you have questions, comments and suggestions. Email us at BACON@mmc.org. We're itching to hear from ya.
Mike: [00:17:23] BACON is produced by the MaineHealth Accountable Care Organization with help from MaineHealth Educational Services.
Julie: [00:17:30] Thanks for joining us. See you next month.
Mike: [00:17:32] See you then.