Last week marked the one-year anniversary of the arrival of Lawrence Moss, M.D. to Nemours Children’s Health System as its president and CEO. Nemours Children’s Health, the only multi-state pediatric health system in the U.S., with tertiary care hospitals in Wilmington, Delaware and in Orlando, Florida, and broad pediatric care locations in Delaware, Pennsylvania, New Jersey, Florida, and Georgia.
Meanwhile, Dr. Moss appeared on Oct. 7 at the 2019 Medicaid Managed Care Conference in Chicago, where he spoke on the topic, “Enhancing Payment Design for Children to Integrate Social Determinants, For a Healthier Medicaid Managed Care Population.” After his presentation, Dr. Moss sat down with Healthcare Innovation Editor-in-Chief Mark Hagland to talk about the current landscape around population health management in the pediatric care delivery space. Below are excerpts from their interview.
One year after arriving at Nemours, what does the landscape look like, around value-based care delivery and payment in the pediatric care space?
Nemours is a tremendous organization; I came to Nemours because I truly believed we have the opportunity to change the way America cares for kids, and I still believe that.
What have the biggest challenges and opportunities been so far?
The challenges are the same as the opportunities. Across the industry, we’re having radical conversations about transforming healthcare that we arguably have never had before, and things are on the table that never were, including how we define health and healthcare, and how we align incentives on behalf of the patient. So it makes for a tumultuous time, and a lot of people are troubled by that, but I just see it as a tremendous opportunity.
You spoke on the topic of enhancing payment design that integrates the social determinants of care. Can you comment on that?
The theme of that is really at the core of what we’re doing at Nemours, which is redefining the meaning of health. Medical care is responsible for about 15 percent of health, and we have the opportunity to try to look at the other 85 percent now. And that means addressing education, literacy, freedom from poverty, safety, the avoidance of adverse childhood experiences, and other elements that impact health status. A relatively small investment in those areas can yield massive returns, not only for children now, but for those who will be the next generation of adults.
How do you see the landscape around addressing the social determinants of health now, as more and more providers and payers are trying to do so?
As you know, the evidence is iron-clad that small investments pay huge dividends, and that making those investments works. The challenge is that the way healthcare is financed in the United States, we get paid for medical care, nothing else. We had a pilot project run out of Nemours that was able to take advance of a $3.7 million grant called the Health Care Innovation Award (HCIA Round 1), from CMMI [the federal Center for Medicare & Medicaid Innovation]. Using the funding from that grant, we were able to take a holistic population-based approach to asthma, and through a variety of interventions, we were able to cut the entire rate of asthma across the entire population, a large segment of the population of Delaware. And across that population—not just our active patients—the incidence of ED visits fell by 60 percent, and inpatient admissions went down 44 percent, over the course of the three-year study. But that activity is unsustainable in the current model, because all of those interventions are a cost. And the better they work, the bigger the financial hit to us. So in order to continue that work forward we’ve got to transform our payment system at scale.
How did you achieve those advances in terms of the reductions in ED visits and inpatient admissions?
We made use of two levels of programs and activities, led by navigators and integrators. Navigators worked at the patient level - community health workers, care managers, home health, everything built around the patient and family. Integrators worked on society-based interventions, including getting ordinances around smoking changed, and extremely simple things like asking school bus drivers to idle with their engines turned off instead of on.
Believe it or not, that intervention had a huge impact on ED visits for asthma. But the link between occurrences and interventions isn’t made if you’re provider-centric. There’s a whole population of kids out there with asthma, and there’s life outside the hospital. If we can make the right kinds of practical interventions, it markedly changes who ends up in the hospital. And, more broadly speaking, if our healthcare system were paid to keep people healthy, that would result in a huge win for everybody.
Tell me about your current payer mix?
Across the entire organization, we’re 55-60 percent Medicaid, and 30 percent commercial, and the remaining portion comes from a variety of other sources, including military, international, charity care. So it’s largely Medicaid and commercial.
And in that, Medicaid, nationwide, is becoming more and more managed care now, correct?
Yes; almost the entirety of our business is Medicaid managed care. I see it as a positive, because it gives us partners to work with. Right now, it’s the managed care companies; in the long run, it should be us.
There are advances being made in Medicaid managed care that might really push the industry forward, right?
I agree. That’s why I’m here at this conference, to develop closer contacts with people in that world. Because when kids are healthy, everyone benefits.
Tell me about the data analytics needed to support this work?
We’ve developed a value-based services organization, so we’ve formalized everything—and people, processes, and data are the three components of that. With people, it’s all about getting all the forces that can affect the child’s health together, and aligning everyone’s views. What we really need is a cultural transformation. But we started out by putting everybody under the same leadership structure and helping to get them aligned. With respect to processes, it’s promulgating the concept of what “our patients” means—and that doesn’t just mean those who come to clinic or to the hospital. We should be just as interested in helping the ones we haven’t yet seen as those we have. And that’s a very different mindset than it’s ever been in this country.
Are some of the core challenges marrying clinical and claims data, and bringing in data streams from so many plans, or both?
Yes, it’s both. We’re doing better, certainly, compared to even five years ago, but we have a long way to go. And understanding how we use claims data optimally, but realizing when we need clinical data to supplement it. And the fact that we’re even having that discussing about claims data compared to clinical data, someday, I hope that will be an obsolete conversation.
How our value-based services organization has been analyzing readmissions data, which is a hot-button issue, and one that we and all healthcare systems care about. We’ve been able to identify readmitted patients who are not medically complex. We’ve got a data set for medical complexity and one for readmissions, and we bring them together. And that’s an opportunity. Perhaps there’s a social, community, historical or communications reason that’s readily addressable, when a non-complex patient is experiencing repeated admissions.
How do you see your work around data analytics evolving in the next few years?
I think the gains that we need to make in the coming years are about our facility with and ability to use the data. It’s not going to be all about better technology and faster computers; the technology is there. The limiting factor now is our ability as organizations to use it effectively.
What kinds of teams do you have working on the data analytics, and how many people are focused on analytics in your organization?
Out of 8,000 employees, we have about 150 focused on data analytics in our organization, so that’s not an insignificant enterprise. This is not a side project for us; it’s at the core of what we think delivering quality healthcare means.
We have IT professionals, data scientists, and clinical people, and we try to marry the clinical and IT knowledge. But we can’t hire fast enough those bright young people who can analyze the data sets. And you put those bright young people together in a room with the clinicians, and you get tremendous clinical insights. And also, we focus on feedback, making sure that those data analysts and the people sitting in front of the data screen, can see the meaningful impact on the kids. That builds huge enthusiasm.
Your organization has made very significant advances in creating patient and family engagement around telehealth and care management. Tell me how that work relates to population health management and the like?
I view telehealth as a very important component of an overall system of care, one that I think will increasingly be utilized and an increasingly important part. The limiting factor is families’ willingness to be comfortable with that system and use it. At Nemours, we’ve invested very heavily, and have very sophisticated telehealth capabilities, and our use rate has gone up every year; but the limiting factor has been the willingness to use it, and that’s the cultural shift that takes place over time. But if you have a child who needs care and can get it more quickly and efficiently, and the parent doesn’t’ have to take a day off work, that’s great, and the result is a healthy child.
What is your vision for the journey of your organization in the next five years?
My dream is that within five years, we will be at full financial risk, full capitation, for every child we care for. That’s my dream. I think that the sooner we get there, the better for children, and the better for Nemours, because our incentives will be aligned. And I see our system increasingly involved in social factors outside the hospital—education, literacy, food security, safety, avoidance of adverse childhood experiences—and we won’t do it alone, we’ll have partners. We’re experts in delivering medical care, but we’re in the business of health, which means we need to partner with other agencies and folks expert in those areas. But the fact that we’re not experts doesn’t mean we’re not accountable. And we will continue to be a leading academic medical center, with research and educational programs. We’ll still be pushing the envelope of tomorrow’s care, and training the next generation. You can’t separate those.
