As we move toward accountable care models, one of the biggest challenges is essentially the same for all of us: How do you assess a population and identify the patients with a chronic condition? And, for those with that condition, how do you identify gaps of care and necessary interventions and evaluate patients against care measures, including those defined in the payer contract? More broadly, how do you transition to a value-based payment system where you must deliver quality care while effectively managing costs?

Solutions, of course, vary by individual market. In Des Moines, Iowa, we have two competing health systems: Mercy and Iowa Health System, which operates a statewide network of hospitals. On the payer side, we have the government and a dominant commercial insurer.

Regardless of these conditions, we at Mercy Medical Center concluded that we needed to address accountable care head-on, with a goal of reducing readmissions and unnecessary visits by patients with chronic conditions.

As a result, we’ve entered into multiple accountable care payer contracts and established an insurance plan for employees. We’ve also formed our own accountable care organization (ACO), bringing in both employed and independent physicians. Most recently, we’ve expanded our ACO collaboration to the University of Iowa and multiple independent hospitals statewide.

Gathering and Generating Actionable Data

As we move toward delivering coordinated care to populations, there’s an obvious need to have the healthcare information technology (IT) systems to identify and analyze the populations you serve. The first thing we needed at Mercy was a disease registry to enable us to track which patients had diabetes, COPD or heart failure. We needed information about their last stay and their progress against goals. We’ve been gathering that data since 1998, but we’ve been doing it manually.

In 2011, we added our electronic health record (EHR), which feeds our disease registries directly and has been a big leap forward. Now, we’re putting enterprise intelligence solutions in place to analyze the true cost of care. This enables us to measure cost and utilization of care to determine which practices drive the clinical and financial outcomes that we seek.

Engaging Physicians and Coordinating Care

With data in hand, the next question is, “How can our data be used to support improved population health?”

To help us leverage that data and effectively manage population health, we hired nurses to become health coaches in all of our clinics. Those nurses identify and work with the sickest patients to follow care plans. They identify patients overdue for care or not meeting goals, and give them the support they need. Typically, when patients aren’t meeting goals, it’s not due to having a faulty care plan; it’s due to patient non-adherence. That’s where our health coaches can make a tremendous difference in reducing risk.

Our health coaches also help coordinate care. Working with patients pre- and post-discharge ensures they’re getting the care they need outside our walls, and that they are keeping their clinic appointments — all with the goals of improved efficiencies and better outcomes. In fact, we have determined that our health coaches return four dollars for every dollar invested. That’s a great investment by any standard.

Sparking the Tipping Point

At Mercy, we’re not waiting for the future to come to us; our goal is to stay ahead of the curve. In his book, The Tipping Point, Malcolm Gladwell explains that when you have a superior innovation—in our case, an innovative care network supported by effective IT solutions—you don’t have to convince everyone to adopt it. You just have to convince the first 20% of stakeholders. For example, once you convince the first 20% of your physicians to align with your strategy, the results will spark the rest to follow suit.

Additionally, Iowa is dotted with small community hospitals statewide. We’re sharing our vision with them, hoping to persuade them to join us. The more lives we spread across our infrastructure, the less it costs each of us. We’re not waiting for insurance companies or government payers to force us to share the risk; we’re aggressively working with these hospitals to partner with us.

But most important is the expected result of our efforts. We expect patients across Iowa to enjoy better outcomes and become a healthier population, and all of us will save money in the process.

David Swieskowski

About the author

David Swieskowski, M.D., currently serves as senior vice president and chief accountable care officer for Mercy Medical Center in Des Moines, Iowa. He’s responsible for organizing Mercy’s Accountable Care Organization and leading the redesign of its care delivery to achieve the triple aim of improved quality, higher patient satisfaction and lower cost of care. Under his direction, Mercy Clinics redesigned its ambulatory Care Deliver system to improve quality and efficiency by implementing disease registries, service and quality measurement, process redesign and new job descriptions.