Dec 11, 2015


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Interviewer: I am privileged today to speak with Dr. Pamela Peele, the Chief Analytics Officer at UPMC Health Plan. She's going to talk to us a little bit today about population health and a really innovative study that she and her team have conducted, taking providers and families out of their silos and bringing them together as a team to really work to improve the health of our children.

Dr. Peele: Yes, that's a very interesting project which was funded in part by the Robert Wood Johnson Foundation and we just finished it. And what we did in that project . . . I want to point out that it's not particularly . . . you're right, in academic medical centers we are masters of the highest level of medical science, and we take care of people, and we fix people, and we do remarkable miraculous things actually go on in academic medical centers, and then we sent people to their communities and their primary care physicians.

In this particular project we identified children who were what we called "medically complex." They were extremely high utilizers of care consistently for 24 months. That was how we identified them. And then we took a sample of them that were in several practices. We ended up with 262 medically complex children. They had all different kinds of disease, it wasn't disease specific, and we tried to think about how do we provide care for this population, not how do we fix a crisis.

And we did that through care coordination, a very intense care coordination which attempted to weave together care across the continuum as opposed to what we normally do which is provide care in silos. I go to my nephrologist. I take my child to the pulmonologist. I take my child to the endocrinologist. I'm taking my child and dropping my child into a silo and getting great medicine in science. But nobody is helping me surf across all of this. I'm always dropping down into a silo.

That was what we did by changing the way we paid for care. We allowed certain types of care to be paid for they're not normally reimbursed under insurance such as multiple providers dropping a bill for the same visit at the same time, so that they could actually have somebody they could . . . one provider could be on Skype and one provider could be in the office with the mother or the father and the child. We paid them to do extensive chart review and a treatment plan in ways they weren't normally allowed to bill for. We allowed for them to bill from multiple other ways for them to bill for what they do beyond the commoditized way that we produced medical services.

Then we incentivized the families. We did a gain share with the families, so that the families were part of what we were doing as well. And in 24 months of demonstration on that project, out of the 262 children and we set up a comparison group so that we could subtract out what was actually happening elsewhere in the world. And we subtracted out the program costs which were not inconsequential, 262 children, put $1.3 million in program attributable net savings on the table over 24 months. So it just goes to show that you can do population health management but you have to line up the resources and you have to change the way that we allow providers to deliver care.

Interviewer: It strikes me as you're talking about this that academic medical centers are actually really well suited for this. The NIH who was one of the major funders of our academic missions has been telling us for years and encouraging us for years to stand up more team science. But when we deliver our health care to our patients, we're still doing it in our silos. And if we can learn as academics to translate what we do in our research mission into our care delivery mission and begin to practice more team-based care, we may be able to make change and it sounds like that was part of what happened within this project. You created teams around these individuals who were complicated.

Dr. Peele: Yes, that's a very good point and that was in fact the heart of how this worked. We had a team-based approach. The specialists were involved. Pharmacists were involved. Nurse practitioners were involved, pediatricians. We put a pediatrician at the middle of the team so that the specialists were truly consultants to the pediatrician, not the pediatrician was sending the child to a specialist and then they never consulted with each other.

That team-based approach also did something that we hadn't quite anticipated. It turned out that the team became an advocate for the child and the family, and that the families became connected to the team. They knew the team. The team knew them. And so instead of going to the emergency room when something was going not well with the child, they called the team. So it really turned into, the team created its own advocacy which was not something that we started off with but it's what ended up, which took it out of the silo.

It was really round primary care. In academic medicine we are the masters of specialty and sub-specialty. This is what academic medicine does and does so well. We can treat very esoteric problems because we have a sub, sub, sub, sub, sub, sub, sub-specialty person who does that. But when we glued the care back down onto the primary pediatrician, then gave the keys to the boss, to the primary pediatrician, that just grew this advocacy that then wrapped the family and the patient around it and now started to be responsive to what the family and the patients' preferences were.

Not just the best science, academic medical centers can deliver the best science this country has. But the personalized medicine which comes out of some of the best sciences this country has isn't personalized care. And what this team did was deliver personalized care. The best science in the way that the family and the patient wanted it delivered.

Interviewer: Really amazing and one of the things that you needed in order to pull this project off was really great data about how much people were costing and how you were saving and investing. But it strikes me that the data and the sophistication of the data that is being used in some of the projects that you're describing goes beyond just beyond the clinical data that we've been thinking about and moves into other realms. What other kinds of sources are you guys using to help try and answer these questions?

Dr. Peele: We use many, many, many difference types of data sources. We use publicly available data. We use census track data. We use household data. We use data from types of magazines people subscribe to. All of these is publicly available data that can be purchased. So we use a lot of that data. We use neighborhood data. We use facility data. We use bus schedule data. We use self-reported health data. That is extraordinarily powerful information.

When a patient or their caregiver tells you that thing aren't going well, they're not going well. And it really doesn't matter what the nurse charted or anybody else thought or saw or how normal the lab value is. It really isn't going well. So that type of self-reported data, while a lot of people don't like to use it, they think it's dirty, it's incredibly powerful data. And then obviously prescription data and encounter data and where and how people are using services.

It's not just that you went to the ED, what happened to you before you went to the ED? So did you end up in the ED because you called your specialist office and they couldn't work you in today so they told you to go to the ED? That's not value-based care. So trying to understand how we deliver care now and how we want to deliver care in the future and academic medical centers are standing at the gates of being able to lead the world in doing this.

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