Groundbreaking Population Health Strategies for Chronic Kidney Disease

<p>we're not trying to steer members away from providers at all we're really trying to make the providers that they've already chosen to be more [Music] atractive hello everyone this is Cole from the American Journal of healthcare strategy joined Again by a really special guest today I had a lot of follow-up questions after we last head him on uh and he's going to kind of give us a really in-depth rundown here uh Eric reamer great to have you on again again congratulations on winning the entrepreneur of the Year award from eyi as we wished you congratulations last time but but thank you for coming on again how is your day going so far wonderful and it's great to be back thank you so much I appreciate that um so of course you're in sunny Florida right now while I am in uh Rainey Philadelphia uh and one of the things that we've been looking into is we're nearing the end of the year here this episode of course will come out in January but we've been looking at work a lot about managing the chronic disease specifically kidney disease Med adherence heart disease kind of all in that area and during our last episode you brought out a lot of important points on your approach to managing kidney disease and so I kind of wanted to ask what is again this approach from a population Health perspective to managing the population what is kind of the first step that you take take when you are working with a client or working with the health system the first step is really to define the population and the way we do that we see the data for our all of the members that we'll be managing we see in addition to folks that have kidney disease we'll see folks with suspected kidney disease so we ask for data on everybody that's uh also been diagnosed with diabetes and with um heart uh hypertension or cardiac disease and then we'll we'll look for uh coding that indicates that they have kidney disease or we'll look for lab tests that indicate they have kidney disease but they haven't been coded then once we do that go ahead call oh no so I'm just I'm interested in the lab portion because the coding makes sense it seems like it would be easy to get the coding I know other organizations do that but the lab portion I think is very unique because you have to essentially be able to interpret the labs are you using a data analytics tool to do that or is there manual review involved you know our system is reviewing that um the the good news about kidney disease frankly is is it's a pretty objective test that if somebody has had the right lab test you can you can see the results and you can tell exactly what stage of kidney disease they have that does not necessarily mean that they've been coded properly by The Physician so we do like to look at those lab tests to confirm diagnosis that is impressive so you really are getting a very high rate rate if not a perfect rate of everyone who has kidney disease who has had the test or has had it you're you're getting that full coverage yeah we want to look for you know both false false positives and false negatives so there are times for example that someone will go into the hospital and they will be coded as having kidney disease and it's really an acute kidney disorder it's not chronic kidney disease and so we really look for multiple uh signs that they've been diagnosed in two settings hopefully not in the hospital setting if it is in the hospital setting we'll really look for a lab test to confirm the diagnosis we want to make sure that we're going to have the most impact on folks and so the way to do that is not to be overly inclusive in the population we're going to be managing it's to get the right population I think that's really important as well so you're you're not looking to to go beyond kind of the realm as we discussed last time a lot of it's about Roi and efficiency so you're also efficient in how you're collecting and organizing the data not just after you have it um continue on with what we were saying though so you get the the data you have the lab test you look for the codes and then what's the next step and then the next thing we do is really look and say really two things with our systems we first we want to know for every member what Physicians do they use uh and for us we talked about this last time and it's critically important that we meet the member where they're at so we're not superimposing some type of of narrow Network Solution on folks we're trying to figure out what uh Physicians that they trust who who do they trust who do they go to most often typically you know it's it's a PCP is clearly on the list and then hopefully in in many cases a nephologist a cardiologist an endocrinologist but quite often as we talked about last time there is no nephologist involved so it's really important that we connect with the PCP as well and so that's one first step is figuring out who we would be working with on the provider side and the second thing we do is RIS stratify the whole population we're taking in all that information that we do have on the member the claims the pharmacy the lab data and we're trying to diagnose who's most lik and trying to predict who's most likely uh to have uh an inverse event over the next year who's most likely to progress into the next stage of kidney disease and we want to make sure we're prioritizing our efforts as any pop Health company would to really focus on those most in need with the most rigorous interventions so those are the first two things we really do the the third thing we do from a technology standpoint is the system is set up to build a customized care plan at scale and this is really important because for our members we're really responsible for their complete uh Total Health really any category a lot of times when people talk about managing a a part of the Health Care System they do behavioral they do oncology they're really only responsible for that portion of the spend and the outcomes we're really taking uh care of the whole member and so what we really want to make sure we're doing with this is understanding as much as we possibly can about those members and um building a customized care plans because if you just look the difference between C take a a health a relatively healthy stage three and an endstage renal disease remember the differences and the needs are so wildly different that we really have to be able to customize it but to do it for 150 to 200,000 people at scale you really need the systems to support that and that's where that Innovation really came in where you had to solve the problem I see another problem though and I've been speaking with other vendors about this and sometimes I receive good answers but a lot of times they're unsatisfactory and so um it how how do you get the data because as a health insurance company they don't have access to the labs all the time they don't even know who the PCP is some of the time so how are you able to actually get that data into your system I'd love to say we have perfect uh a perfect answer but but there is no uh one answer so we get what we can get from the health insurance companies to your point from the in the lab world uh in in particular they're usually pretty good at getting information from Quest and lab core you know the big the bigger players some of the local folks um they have a little bit more challenge getting that that information we will uh all often work with health information exchanges to get some of that information they tend to be a little more comprehensive and then we'll work with the physician as well to understand where the orders were in some cases we're just asking members to self-report what they see on the lab test and and uh again not as perfect as seeing it ourselves on the claim um but better than not asking those questions we're we're always trying to look for whatever source of data we can get right and that was kind of what I had I had seen is it seems like sometimes um the solution is to not get any of the information at all is that ever an outcome that that you go with or or does your team really try to kind of at all costs get the information at all costs we're trying to get the information that said there are cases I'm sure that we aren't able to get everything we we need to get and then we've got to make some inferences and assumptions um but one of the things we quickly try to do is get that member if we don't have a lab test for for them to get them to take a lab test right and get a new lab test so so we we have we don't give up on a case because we don't have perfect information you know again if you think about what we're trying to do with this population we're investing more proactive resources in them getting them to see their doctors getting them to get tested make sure that they're on the right meds and that they're adhering to that so ordering another lab test is is perfect because it gives another opportunity for them to meet with their doctors as well and that that's kind of what I think some people are missing is it's that human connection that's enabling you all to really excel in collecting the data in getting the information and also in making those inferences if if you didn't have that personal connection you'd essentially be making an inference with with not just not enough information and I wanted to ask you you also mention that you're caring kind of for the whole person when it comes to that personal connection with the member what kind of challenges are you helping them overcome is it just related to just the kidney disease or are there other areas as well absolutely not just the kidney disease so I would put the buckets into really in into two so the first thing is when we are trying to work with a member in order to get that member to listen to you to feel good about uh complying with with what you're asking them to comply with you've really got to deal with again the whole person so we deal with the social determinant of Health side um we are make sure that we do a behavioral health screen um if appropriate we'll get them a behavioral health referral and make sure that they get a a therapist that their uh field like is a good fit for them we help with food insecurity we help with housing um and many cases Transportation will help with things like co-payments where a member is looking for an alternative drug because they can't afford a copay and sometimes we can help make it more affordable by working with the Pharma company so we really have an attitude on the social determinance of Health side not about identifying the social determinants of Health that's that's the initial step but then you really have to close the gap and we have worked with folks to make sure that we can get them housing that we can get them food um and you know in a lot of cases there are local charities there local organizations that if you can really connect with they're more than happy they're set up to provide these types of things for our members but it's making that connection that that's so valuable so that's the first part then the second part that we um want to spend time with the member is again really making sure they understand their disease State they have someone they can ask questions to they understand the importance of adherence to their care plan um and and it's it's every day again one of the things that we find is people will say yeah I take my meds you know most of the time unless I have a stomach ache or unless I travel or unless or some days I feel better than others and the days I feel better I decide not to take my my meds depending on the med in most cases these are meds they're supposed to take to feel better and if they're feeling better they're still supposed to take those meds so we really make sure they understand exactly uh what is expected of them to keep them healthier and we do a big uh push always on that compliance side and then we do spend a fair amount of time making sure that they understand the effects of their own behavior that eating um selecting better diet having some exercise setting realistic goals and we'll work with them to help set those goals will have a big impact on their care is that one of the reasons why you open that office in Puerto Rico is because of how invested you need to be in the community for you know there to be success so backing up to Puerto Rico Puerto Rico was a fantastic success story for us um one that frankly a lot of folks um had advised would be a difficult uh would be a difficult launch um for all kinds of reasons right there's different culture there's a different Health System uh you have the language barriers uh Etc we really decided early on we were going to go all in we were going to invest in the islands we were going to build an office in the island we were going to hire our staff on the island uh we have 70 plus uh members there we've also given some of those members some national responsibility which is wonderful to see as well but we we really needed to get close to understand the nuances of the island and and what I will tell you I've learned a lot um you need people in every region of the island you know much like here in the mainland where you know if you're if you're giving some advice to somebody in rural Arkansas or you know Urban Chicago you might need somebody that understands those markets a little bit differently um same is true on in Puerto Rico it's not one thought size fits all people want to work with people that are from their area of the island that understand exactly who the doctors are that understand you know the travel times and things like that and so they and have the ability at times to go see the member l so we've got staff all over um the Ia Puerto Rico and one of the things we did that was essential to our success and the first time we really did it not only did we we always have these Regional teams and people out there um in each area where we have members but it was the first time that they really put a leadership level in place so there are leaders on the island that we empowered to make decisions to customize the programs them to meet the needs of the island and um we're very involved with them they do a fantastic job for their members I'm looking forward to I'm going to be going down there over the next week on seeing our our uh our operation but it's really one of the best run operations best leadership teams that I've seen around the local area and uh I think we may the investment we've seen that it's paid off that is awesome that is and an really important lesson because you know as you were talking or listening off the amazing amount of things that you do for the members and how you really are invested in them and then that office where they are right you know being able to be physically present as a necessity of the organization is really important that kind of leads to the next question which is you know clearly what you do for the members is excellent but a lot of providers they don't like working with vendors especially since there's so many vendors and organizations and companies they have to work with now they're wary of it uh but what's different about your approach is you are really helping the provider you're offering kind of the providers of service how do you do that what what do you do for the provider yes so the first thing I'll I will keep going back and stressing we're working with the providers that the member is already trusting and so that first of all that goes a long way uh that the we're not trying to steer members away from providers at all we're really trying to make the providers that they've already chosen to be more effective and so that that is very very important distinction second thing I'd say is the best way for us to get members to trust us and to be part of our program is to get the providers their provider that they trust to endorse the program so the first thing we do when we get all that data we were talking about before we go to the providers that those members see and ask them uh to be in the program and we show them exactly why they should be in the program and when we do that we don't talk generally about the benefits of the program we don't show up there and say we're going to give you information that will be helpful on your member what we do is we say we've identified 16 members of in in the program that are already seen by you and let me go through four of them where we think we could make a difference through care daps and interventions that we would suggest on four members when people hear about every doctor is working hard and trying to do right by their members and so when you talk generically it doesn't really hit home but when you say I'd really like to talk to you about John Smith who's your patient and what we're seeing with John did you know that he hasn't filled a script in 90 days for a Statin it really makes them feel like you understand their members you're going to make an impact and vice versa when you go to a member and say you know we were just in Dr Jones's office and he feels like it'd be really helpful for you to do X Y or Z the member really pays attention so it really is a symbiotic uh relationship how uh but but what do we give those providers that makes it worth their time so the first thing I would say is again we position ourselves as empowering them not replacing them and so we want to be an extension of their office we tell them we'll be eyes on their members when the member can't be seen by them and we're going to provide insights that other providers I mentioned before some of these folks the pcps and chronologists cardiologists nephrologists we want to make sure they're communicating to each other uh a lot of what happens in the Health Care system is Specialists get involved and they duplicate uh some of the the effort or they assume somebody else has taking care of something we really make sure that we're that connectivity across and that we're creating a community of their doctors that can communicate with each other and make sure we're getting the right Solutions but I'd say specifically our value breaks down into two categories so the pcps you're talking about some of the most complex members they have to deal with kidney disease members might be five or 10% of their panel at most so it's not that every member that they come forward with is uh is a kidney member um so we really have to make sure we're streamlined into their workflow and that means very very different things to every doc so sometimes that means they want us to pour our suggested interventions into an AMR sometimes we they say we'd like all the information to go to one Central um Hub where the nurses kind of Dole out what some of the interventions should be other times they say no we want you to deliver it to the individual doctor sometimes they say we don't want it in the individual in the EMR because one of the things we do the most is trying to get doctors who don't go into the office to get care and if you put in the EMR the really the only time the doctor sees it is when they pull up the EMR when the M's in front of them so you're missing out on a big portion of what we're trying to accomplish so the pcps it's really about simplifying for them what these members need communicating back on on what these uh other Specialists are seeing and making sure that the PCT that pctp really understands their role which is you know make sure that person's getting their vaccinations make sure they're asking them about their comorbidities make sure that they're really taking care of some of the basic needs of these members where the specialist may not be attuned to that um the nephologist it's a different situation the nephologist we've talked before about how the access is so tight and we want to keep that access broad by including everybody who's in the network in our Network in addition you want to make enable the nephologist to see as many members as they can see efficiently and so getting them data that's action oriented is is really important so the first thing is making sure that the data is presented really crisply so that they they can intervene the second thing is members have a lot of questions of the nephrologists they really want to understand their disease they want to understand dialysis they want to stand their opt understand their options and so we can take that burden off of them and educate the member over a series of conversations with our nurses so that the nephologist doesn't have to spend that time with the member and they can spend it on things that only the neurologist could do and that's where the PCP and the nefrologist E see value and what we're bringing to the table that is awesome wow so everybody is benefiting tremendously and and honestly I'm really impressed with the focus that you are all putting not just on the member but you're putting a tremendous amount of focus also on the physician on the provider whether a specialty or primary care I think that dual Focus I mean you know that sounds like that'd be hard to maintain those those focuses uh I think that you know kind of alludes to why you won the entrepreneur of the Year award because it's it's really a challenging balance and then you also have that third part which kind of um incorporates that that joint collaboration which is the the payer the the uh the insurance company the health plan and what you I guess one of the questions I have is you know what's the ROI looking like for the health plan because I feel like this is a service that every Health Plan want to to incorporate so the way we structure our Arrangements we have to drive better outcomes clinical outcomes and savings for the health plan to get for us to get paid and so um we are very very focused on a series of clinical outcomes adherence to meds uh reductions in admissions a reduction in readmissions getting people into nephologist reducing the crash rates so we and and reducing progression of disease so we have very quantitative ways to show that we're adding value in addition we've got to show that that leads to savings and and those are it's so important to have both you know there's there's a lot of um in the news about you know health care and health insurance companies and making sure that people get to get their services we're not doing anything to deny Services we we are making sure that people get the care they need um in a proactive basis and again this is a population that you want to invest more in not less and so we really are are have to show that the only way to make this an impact on this population to the longer run is to make sure those clinical outcomes are getting better not just a cost we do that on the clinical outcome side but ultimately what save what funds the program is this is the savings and really the equation that we've got to continually show is how how much are we saving by reducing impatient stays by getting people better proactive care eliminating those events and then showing that that outweighs the fact that we're spending a little bit more on physician costs on drug costs on lab costs and uh inevitably that that equation always works out you know we have in every case we have found that investing a little bit more in those physician labs and the drugs um and then the time it takes to work with with the member um always results in enough reduction and inpatient cost to more than offset that cost so it's it really is a win for everybody I think that's it's a historical saying right what is it an ounce of prevention is a pound of C but that's really true right and I think that what I appreciate is that you're using kind of a value based you know payment model it sounds like right from what we talked about where you only get paid when you provide value but it's so important and I hope people really realize how important it is that it's not just the savings based you said it's also that quality and outcome based because what we don't want to happen is an initial savings windfall that over the next 10 years harms your organization through other quality metrics that could be lacking and so the fact that you've Incorporated that speaks also to how it it's a team of both clinicians you know data scientists and administrators on your team as well right you have a lot of clinicians that are evaluating your procedures from what I understand absolutely and more so than not I would say our primary contacts at the health plans are the clinical teams they they are you know obsessed with making sure that these populations that need the most help get the best care and so we absolutely work with them and and again want to show that those clinical indicators are are moving uh in the right direction materially and uh we're able to do that that is great thank you so much Eric for explaining this really in depth to me and uh I'm excited to speak with more members of your team in the future and understand different aspects of of the business I've learned a lot I know going into my my pop Health PhD this fall hopefully uh I'll get admitted I'm sure this will be a great benefit to me and and to everyone else listening uh thank you so much Eric for your time uh we appreciate it but you know the truth is it's we're doing such good work here that getting that message out is always a pleasure to discuss so thank you so much</p>