Provider Insider

Issue 4

Table of Contents

Leadership Message

We have come a long way in our two years as a clinically integrated network and experienced change time and again. But those changes have been an impetus for growth and opportunity, and have yielded a multitude of accomplishments. Together, we have built a network that is committed to results and includes:

  • More than 3,000 providers in Colorado and Wyoming who manage more than 100,000 unique lives attributed to value-based contracts.
  • A single instance of electronic health records that integrates both clinical and claims data – allowing participating providers the opportunity to understand the full picture of a patient’s health across the full care continuum.
  • Access to evidence-based protocols and clinical initiatives with one set of consolidated metrics for cost, utilization and quality reporting.
  • Data analysts who unify clinical and claims data in electronic dashboards to identify potential care gaps and help develop strategies for improved performance across each of our value-based contracts.
  • Pharmaceutical support for providers that includes clinical interventions and recommendations to better manage the cost of prescription medications.
  • Clinical transformation and care management teams for consultation and support.
  • Opportunities to lead – members may choose to join a work group to discuss clinical strategies and areas of improvement.

 

Most importantly, our efforts have yielded success in our value-based contracts:

  • Anthem Commercial EPHC Calendar Year 2017 results – the network improved quality from 50% to 60% and created shared savings of $1.78M.
  • Cigna Commercial CAC Performance Year 2017 results – the network improved quality from 56.3% to 82.4% and created shared savings exceeding $615K.

 

If we can be certain of one thing, it is that more change is yet to come. We hope you will embrace it knowing it will only make us better. This network is on a trajectory destined for success, and collectively we are unstoppable.

 

Austin Bailey, MD

Medical Director, Network Engagement for Population Health

Network News

An update about what is happening within Coordinated Care:

If you have news or announcements to share with network colleagues, please send to PopulationHealth@uchealth.org and include Provider Insider News in the subject line.

 


Welcome new members.

We are pleased to welcome new members to the network:

  • CU Urology – South Denver (July 2018)
  • CU South Metro OBGYN (Oct. 2018)
  • CU Orthopedics – Broomfield (Dec. 2018)
  • UCHealth Sterling Ranch Medical Center (Sept. 2018)
  • UCHealth Primary Care – Yosemite (Dec. 2018)

Coordinated Care is composed of primary care and specialty practices from Pueblo to Steamboat Springs and includes UCHealth Medical Group, CU Medicine, Associates in Family Medicine, UCHealth Family Medicine Center- Fort Collins, and several independent practices. These entities represent more than 3,000 providers and 100,000 attributed lives.

 

As we continue to grow Coordinated Care’s footprint in Colorado, we improve patient accessibility and increase our value to those whom we serve.

 

 

Anthem EPHC

Each year, Anthem publishes a Measurement Period Handbook that details upcoming changes to the EPHC program. From that handbook, Coordinated Care’s clinical committee identifies those quality measures the network will prioritize as areas of focus for the coming year. A summary of general changes follows.

 

Note: All current measures of focus are included in the 2019 program; however, confirmation of those measures on which the network will focus in 2019 will be forthcoming.

 

Quality Scorecard Enhancements:

  • Retired measures: Diabetes Eye Exam, Annual Monitoring for Patients on Persistent Medications: ACE/ARB and Diuretics, New Episode of Depression Effective Acute Phase Treatment and Effective Continuation Phase Treatment, Proportion of Days Covered (PDC) Oral Diabetes and Hypertension (ACE or ARB), Well Child Visits 12-21 Years Old and Ambulatory Care Sensitive Conditions.
    • Please note: There are references to Ambulatory Care Sensitive Conditions within the Enhanced Personal Health Care Program Description. On and after January 1, 2019, these references will no longer be applicable due to the changes made to the MPH. The next Program Description will delete all such references.
  • Revised measures: Medication Management for People with Asthma for Adults and Pediatrics has been revised and renamed to “Asthma Medication Ratio.”
  • Potentially avoidable ER metric: New listing of more diagnoses codes will be implemented.
  • National Centers for Quality Assurance (NCQA): Removed references to Patient Centered Medical Home NCQA throughout the MPH as it is no longer part of the scorecard.

BlueCard membership will be included in the benchmark risk score calculation and also in the Physician Quality included in the Performance Scorecard for measurement periods July 1, 2018 and forward.

 

65 and Older Attribution Inclusion:

Starting October 1, 2018 MP and forward, the 65 and older actively working adults will be allowed into attribution of all commercial programs to provide the benefit of care coordination to Members and Shared Savings opportunities to Providers.

 

A geriatric risk adjuster has been put in place to normalize the PMPMs for risk. The Quality and Utilization Metrics below could now include the 65 and older population as they are now included in your attribution.

 

MSSP

Earlier this fall, the Coordinated Care Board of Directors agreed to voluntarily exit the Track 3 Medicare Shared Savings Program (MSSP) offered through the Centers for Medicare & Medicaid Services (CMS). The decision followed a shared loss in 2017 and protects the network from further financial risk in this program.

 

Following the board’s decision, Chief Population Health Officer Jean Haynes notified participating providers and has distributed subsequent communications answering frequently asked questions and detailing related CMS closeout procedures.

 

This decision does not in any way impact the network’s long-term commitment to improving the health of the populations we serve, and we will continue actively managing more than 100,000 unique lives across multiple payers and programs.

 

Please contact Kristyn.Ulrich@uchealth.org with any questions.

 

 

2019 Engagement Summit

The Coordinated Care Engagement Summit has been rescheduled for January 31, 2019.

We welcome you to join us for this event. Please register your attendance here, as space is limited and reservations are required.

 

Description:

  • Discover Coordinated Care’s strategies for effective population health management.
  • Participate in round-table discussions addressing questions from network providers.
  • Hear from a panel of your peers as they share their achievements in improving ED utilization.
  • Learn more about the value of integrated clinical pharmacy and how to leverage analytics to improve patient care.
  • Engage with your partner providers, and find out how others are using evidence-based data to reshape practice infrastructure.

Breakfast, lunch and refreshments provided. Validated parking.

 

 

Network administration staff updates.

Coordinated Care is growing, and so is its administrative team. The following individuals recently joined us in supporting the network:

  • Joselyn Benabe, PharmD, BCACP – Clinical Pharmacy Specialist
  • Valerie Carter – Care Manager RN
  • Anne Docimo, MD, MBA – Chief Medical Officer
  • Kate Lipstein – IT Program Manager
  • Nicole Petersen – Administrator Special Programs
  • Kassandra Salazar – Administrative Support

Network Development

Coordinated Care continues to mature in its developmental path, and has demonstrated success in its first two commercial ACO programs. But that hasn’t stopped our network engagement team from continuing to meet with practices and affiliated leadership teams on a regular basis.

 

“These meetings have helped identify care opportunities with the populations we manage,” said Paul Staley, director of network engagement. “As a result, we have been able to help practices incorporate processes to close care gaps and reduce avoidable ED visits.”

 

This work better positions the network to qualify for shared savings in its value-based contracts.

 

Current procedure relies on practices to work with their own panel of patients to close care gaps and reduce avoidable ED visits. Most practices have resources that help manage the provider’s panel with closing quality care gaps. And they have same-day appointments, extended hours or a provider on call to help direct their patients to the appropriate level of care to reduce avoidable ED visits.

 

For those that do not have those resources in place, the network engagement team can help by working collaboratively and creatively with practices to overcome those hurdles. Depending on the situation’s requirements, there could be an associated cost. But sharing resources among several practices can make it surprisingly affordable.

 

“We are very appreciative of all the efforts practices demonstrate to take care of the populations we serve,” Staley said. “Our team is always interested in improvement opportunities. If there are ways that the network engagement team can be of greater assistance, please bring your ideas to our regular meetings or contact us by email. We’re here to help.”

 

Please contact either Paul.Staley@uchealth.org or Austin.Bailey@uchealth.org with questions, comments or suggestions. And keep up the great work.

Pharmacy Integration Insights

Currently, there are seven U.S. FDA-approved statins on the market and available for use: atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin and simvastatin. While the medical community is certain statins significantly reduce the risk of vascular events and cardiovascular mortality in high-risk patients, the choice of which statin to use in a specific patient is not always as clear. Not all statins are created equal and differences in their lipophilicity, potency and pharmacokinetic parameters can impact patient response.

 

Coordinated Care is actively and diligently working to improve the use of statins in patients with diabetes using collaborative approaches that include providers, clinical pharmacists and other health care team members. The current initiatives to date (e.g., Epic Health Maintenance tool, pharmacist chart review with recommendations to providers) have been effective in identifying patients who may benefit from statin therapy. The choice of statin for a specific patient is, ultimately, at the discretion of the prescribing physician.

 

To optimize the use of statin therapy, clinicians should consider several factors when selecting a specific statin drug for a patient. The goal is to maximize drug efficacy and patient tolerability to ensure patients remain adherent to their statin therapy.

 

Factors to consider when choosing a statin:

  1. Indicated statin intensity based on evidence.
  2. History of statin use and intolerance.
  3. Patient adherence.
  4. Drug-drug interactions.
  5. Renal function.

Indicated statin intensity.

It important to first identify patients who are indicated for statin therapy as well as the level of statin-intensity that should be utilized in those patients. The 2018 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults1 outlines four statin benefit groups and provides recommendations on statin-intensity based on a large body of clinical trials.

LDL-C: low-density lipoprotein cholesterol.

 

High-intensity statins lower LDL-C by at least 50 percent on average while moderate-intensity statins lower LDL-C by approximately 30-49% on average. The table below outlines the specific statins and doses for low-, moderate-, and high-intensity statin therapy.

 

Statin hydrophilicity.

The available statins differ in how water-soluble (hydrophilic) versus fat-soluble (lipophilic) they are. Statins that are lipophilic tend to distribute more into the body’s tissues as compared to hydrophilic statins. In patients who have a history of statin intolerance due to muscle-related adverse effects (e.g., myalgia), choosing a statin that is hydrophilic may be better tolerated due to less distribution into the body’s tissues.

 

Statin half-lives.

Statins also differ in their half-lives affecting their overall duration of action. Some statins are considered to have short half-lives and should be dosed in the evening when LDL-C production is highest in order to maximize their effect. In contrast, statins with long half-lives can be dosed at any time of the day due to their longer duration of action and may be more optimal in patients who have issues with adherence.

 

Drug-drug interactions.

Lastly, the potential for drug-drug interactions should be considered when selecting the most appropriate statin for a patient. Drug-drug interactions with statins can increase risk of adverse effects with statin therapy which may deter patients from maintaining statin therapy. Several statins are metabolized through the cytochrome P450 (CYP) pathway. Simvastatin and lovastatin (and to a lesser extent atorvastatin) are metabolized by CYP3A4 and are therefore most likely to have drug-drug interactions. Pravastatin is not metabolized through the CYP pathway and is a good option for patients who may be on multiple other drugs that affect CYP enzymes. In general, gemfibrozil should be avoided with all statins. The table below provides a list of select interactions that are commonly seen in clinical practice.

Note: this is not an all-inclusive list of statin interactions.

 

Renal function.

According to the 2018 ACC/AHA Guidelines, it is not recommended to initiate statin therapy in patients with advanced kidney disease who require dialysis treatment. In patients with chronic kidney disease not on hemodialysis, it is useful to consider urinary excretion of statin medications when choosing statin therapy. Atorvastatin and fluvastatin have the least urinary excretion, and may be the best choice in individuals with impaired renal function. Although only 10 percent of rosuvastatin is eliminated in the urine, it should be used cautiously in patients with decreased renal function because its long half-life can increase serum concentrations.

 

 

Bottom line.

Given the magnitude of benefit that statins provide to our patients in terms of cardiovascular morbidity and mortality, it is essential we select a statin that is both evidence-based and will be best tolerated by the patient to ensure continued use.

Metabolized through CYP2C9, so would need to avoid in some situations.

 

 

Questions or comments? Please contact Joseph.VandeGriend@uchealth.org.

 

Marina L. Maes, PharmD and Marina S. Snellings, PharmD authored this article. They are both second-year ambulatory care pharmacy residents with the University of Colorado Skaggs School of Pharmacy and provide clinical pharmacy services to patients across the UCHealth Clinically Integrated Network.

 

References

  1. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. J Am. Coll Cardiol, Nov 2018, 25709; doi: 10.1016/j.jacc.2018.11.003.
  2. Venero CV, Thompson PD. Managing statin myopathy. Endocrinol Metab Clin North Am. 2009 Mar;38(1):121-36. doi: 10.1016/j.ecl.2008.11.002.

Clinical Transformation Insights

Diabetes is a disease and left untreated can lead to serious complications. Proper diabetes management includes controlled blood glucose to thus reduce complications and prolong life. Not surprisingly, all of Coordinated Care’s value-based contracts include at least one quality metric associated with diabetes.

 

The National Committee for Quality Assurance (NCQA) is an independent organization that works to improve health care quality through the administration of evidence-based standards and considers comprehensive diabetes care to include hemoglobin A1c (HbA1c) greater than 8 percent controlled. The network’s clinical committee sanctioned this standard of care last summer, and a team of technical analysts has been working to build a measure in Epic to track performance. The measure is now live within Epic’s Primary Care Quality Dashboard and the Power BI reporting tool. Current performance is displayed below.

Epic clinical data only, claims data is excluded. Patients 18-75 years of age with diabetes Type 1 and Type 2 who had an HbA1c < 8% in the past 12 months.

 

Prioritizing diabetes care management.

Several network partners have implemented clinical care delivery models to improve the care of their diabetic patients:

  • UCHealth Medical Group implemented an improved clinical pathway for their diabetic patients.
  • Associates in Family Medicine implemented a pre-charting process for diabetic patients and enhanced their rooming workflow for optimal care.
  • UCHealth Family Medicine Center – Fort Collins piloted diabetes-specific clinic appointments and increased appointment slots from 20 minutes to 40 minutes.

Time will tell how significant an impact the network’s enhanced clinical pathways will have on the population. In the meantime, we encourage you to use this mechanism to track performance. The newly implemented HbA1c measure, along with other diabetes quality measures being tracked (e.g., Diabetes Nephropathy Screening, Diabetes Statin Compliance Rate and Diabetes Hypertension), provide a comprehensive look at the health of the diabetic patient population.

 

For more information, please contact Michelle.McLeod@uchealth.org.