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Good morning. This is Alan Pitt with Healthcare PittStop. Today I have with me a friend and expert on population management for Dignity Healthcare, Julie Bietsch. I was hoping she could talk about population management and about my interest, telemedicine, and how those two may fit together. Welcome Julie. How are you?

I’m doing great, Alan.

Julie, you’ve had a varied background. You came from the insurance space. Can you tell me a little about your background and how you came to Dignity?

I’m a nurse, and for about 29 years I have been working for the payers—United Healthcare and Anthem. I’ve done everything including operations and contract negotiations with hospitals and physicians. For the last 3 years at Anthem, I ran the clinical programs: disease management, and case management. I left Anthem in 2012 and joined a company called Evolent Health, where our job was to teach population health management to health systems. I joined Dignity in 2014, and have been working in clinically integrated networks, population health management, and managing financial risk contracts.

That’s such a new space. Many of the folks listening may not know what population health management is. In fact, I told a friend that I was going to interview an expert on population management and they asked me if that was a form of birth control. What exactly is population management?

The definition varies depending upon the person who’s defining how to manage a population. But the way Dignity defines population health management is, we’re trained to help the people who seek healthcare or live in the health communities in which we serve. We’re focused on the members who are assigned to us because of a contract with the state, the federal government, or the payer. What we offer to those patients is [a way to] think of us as more than an episode of care. Say you’re sick, you have congestive heart failure, and you go to your doctor. But what population health management [proposes] is that maybe you shouldn’t just come for the doctor. Maybe we should call you to make sure you’re doing okay. Maybe we should check to see how your weight is doing, to see if you’re getting sicker from your congestive heart failure. Or maybe we should look beyond healthcare. Maybe there are things in the community that would help you manage your healthcare or your social needs. So it’s thinking beyond the event—that you’re sick [and] you have to go see someone, a hospital or a physician—and trying to keep you well. 
 
A lot of people talk about social determinants of health. Folks like Kaiser, like Dignity, would kind of take some risk around housing, food, and health—really wrapping that person in a blanket and making sure that they’re okay. It’s a tough space, I know, particularly for some of the poor.

Think about what’s important to a person. If a person doesn’t have a home, doesn’t have the ability to pay for food, doesn’t feel safe in their environment, the last thing they’re going to be thinking about is their nutritional needs to support their diabetes. They’re going to be in what we call a “fight or flight” situation. So Dignity is really taking a different look at how we help patients with their social needs. For example, in Los Angeles a lot of our patients are homeless, are in Medicaid populations, and when they’re trying to figure out how to manage their diet for their diabetes, their only food source is a food bank. When the food bank does not have healthy food options for you, how can you be compliant with a diet that is prescribed for you? So we’re really looking at how we can improve the homeless situation. A lot of grants that we provide to our communities are to support the social needs of patients to help them better control their healthcare. 

That’s awesome that you’re looking at that patient holistically. You know, lots of folks in America are on pause thinking that as we shift from Obamacare to Trumpcare things may just revert. What do you think is going to happen with the new administration? Do you have any crystal ball in terms of where that’s going?

We’ve been following it as closely as you have. Some things we believe are not going to change. We believe that you’re going to have to offer coverage for children up to the age of 26 under a parent’s policy. We believe you have to provide services for patients even though they have a pre-existing condition. But we are very worried that the federal funding will be reduced to the states to cover Medicaid programs, which will put our states in a very difficult situation if they don’t have those matching funds. We also think the tax credits are going to change dramatically for individuals. So for people that are getting the premium credits, not only is your insurance premium going to increase but your credits are going to decrease. So we think there will be more people forced into not having coverage. And we’re very nervous about what that means to our population. We also think there are going to be some changes to mandated coverage. [As an example of the impact of that], I have a Sister who’s very healthy, and if she had taken the ACA program, it would have cost her $785 a month this year. But we were able to find her another program that cost her $350 a month. The difference is she doesn’t have substance abuse coverage or elder care. Well, she’s 65 years old and she’s healthy. So we think that forcing people into a defined health plan will no longer be part of the ACA.

 

I know Lloyd Dean has made a public pronouncement that he wants to double the [number of] patients he takes on at risk, meaning that if he doesn’t deliver on the costing structure, then Dignity’s on the hook. Do you see him or Dignity backing away from that position?

Not yet. We’ve talked to Lloyd and his executive leadership team, and even if the state or the federal government changes how the ACA looks, we’re very focused on delivering value-based services. Fee-for-service, we believe, will always exist—that’s a mechanism on how people get paid. But we think there will always be incentives tied to this new value-based program’s quality of care, access to care, getting clinical pathways designed so people can get standardized clinical treatment that will be much higher quality and lower cost. Lloyd is also very committed to changing the way our costs work, from a hospital perspective. We can no longer have—[as we do in] in Sacramento—4 hospitals that offer all different cardiac services. We need to start consolidating services so that we can provide the best service.

The emergency room seems to be ground zero for population management. Part of the problem there, of course, is that the poor are underserved, and when they don’t have any skin in the game, that’s an obvious place to go. Do you have any thoughts on how to move those patients out of the emergency room and into lower-cost options for care delivery?

Our mission is to support the poor in our communities, and that means providing them access to care. I’ve been spending a lot of time in LA [looking at] why our patients are using the emergency room. Number 1: There is no co-payment or co-insurance, whereas there may be a minor co-payment or co-insurance at a doctor’s office. So you need to make the financial necessities align with the path you want the patient to follow. Number 2: These are patients who have to work. They cannot take off work because their doctor can only see them between 9 and 5. They have to be able to have access in the evenings and on the weekends, have telephone access to services they need. They need to have alternatives to going to the emergency room for services. Until we fix our access problem, we won’t fix the emergency room problem.

 

I call healthcare “compassionate capitalism.” You have to figure out the business model, the motivators, to actually take care of the sick and the poor.

 

Shifting gears a little, I spend a lot of time thinking about medical collaboration telemedicine. Often there’s a disconnect because telemedicine tends to be a technology-centric thing. Do you have any advice for the telemedicine community? I think there’s something there that we can help you with in terms of how we work with population health executives like you.

 

We are very interested in telemedicine and how to use it. We think it’s a lower-cost option than having every person come into the office. It’s more convenient and attractive to our senior population—they don’t have to leave the home if they don’t need to. It’s attractive to our Medicaid population, who need access after hours. It’s attractive to our Millennials, who don’t want to necessarily establish a primary care physician relationship but just want an answer to a situation. So we think the solution is very attractive. It has to be affordable, and we need to make sure federal, state, and private payers are paying for this solution to be added. And it has to be a really easy technology solution to engage the population. The people I know that have used a tele-solution have been very pleased with the services they have received.

 

One of the most pressing issues we have is the growing elderly population [and the way] skilled nursing is disconnected from the hospital. I’ve often thought that telemedicine, by reconnecting the nursing home to the hospitalist and to the hospital, would work well. Any thoughts on how we could bring skilled nursing into the fold of telemedicine, what a business around that would look like?

We’re pretty excited. We’ve been talking to a number of companies on virtual solutions where we would start with our preferred providers and preferred skilled nursing facilities. We’d set up a room, the patient would come into the room, we’d have this video equipment set up, and with the assistance of the nurse who’s on site, we could do the assessment that’s needed for the patient. We would have the hospitalist or the intensivist or gerontologist on the other end of the video, and [while] we’d be walking through the issues with the patient, [that specialist] sees the patient, is having interaction, and they can then submit the orders to care for the patient. Now the patient doesn’t have to go to the hospital. We’ve saved the ambulance transportation, which is hard on the patients. A lot of our patients—especially the elderly—don’t do well with hospital transportation [or being] out of the comfort zone of their common routines. So we think it’s a win for everyone if we could put this in place. And we’ve been talking to two agencies about this.

So you’re just at the early stages. I would think it would a differentiator for the skilled nursing facility who’s looking to get patients into beds to offer that as a service as well.

Exactly.

Dignity has had some experience with direct-to-consumer online care options. You had Doctors on Demand for a while, and it’s being reassessed. Obviously it would make a lot of sense for a patient to be offered an online option. Any perceptions—good, bad, or indifferent—on how that’s going?

I don’t think we’ve figured it out yet. We have theoretical concepts of how this should work, but you have to have staffing involved, you have to have a way to transmit orders, to get information back to the primary care physician. It’s been a tough one for us. We haven’t come up with a totally good solution. But we do have some sites, [such as one] in Woodland California that does more consumer online care, and they love it. We have nurse practitioners engaging with the patients, and it’s giving them the solutions they need. So I think over the next year we’re going to see a dramatic uptick of that, but people have to remember technology is just technology. You need to have quality people behind the technology that have the time—at the right time—to deliver the solution.

Do you think that patient monitoring is about to come into its own? Weight scales, glucose [monitors]? It’s a promise that’s not been delivered yet. Do you see that as playing a big role?

[Laughter] At Anthem and Wellpoint and United, we’ve talked about home monitoring. It just hasn’t caught on for some reason. I’m sure there are cases, like I was in St. Louis and I was looking at another company, and they have 3000 patients on some form of home monitoring. But it’s very labor intensive. It’s costly because someone has to monitor the results. The solutions are getting better, but just because your device is in the home doesn’t mean someone stands on the scales. You still have to have a person encouraging the care coordination to happen. So they’re going to keep growing; they just haven’t gotten where they need to go.

I was intrigued recently by a company, Propeller Health, that Dignity has had some discussions with. I really like their approach on educating the patient first and the provider second around that data, which I think is the way to get to scale. 

They’ve done some great work with us.

In the past you’ve mentioned that telehealth needs to facilitate social opportunities. I’m assuming that you mean that we need to figure out ways to engage the family—local or remote—or did you mean something else by that
?

The family’s important. What we have seen is that when there’s a caregiver engaged with the patient, the readmission rates are very low. When we talk about social opportunities, we also mean engaging the community health providers. So besides having to call a doctor when you have a question about your diabetes, what if you took an online telehealth program on how to manage your diabetes? Then you could call them if you had a question.

 

In the community, there are so many resources, but who knows who they are? Who knows if they’re good? How do you get referred into them? How do you get engaged with them? If you think of solutions in the future, we will do assessments—Dignity has been doing them, so we have a program to assess who is in the community and what services they provide—and then let Yelp do a reading on them. It’s kind of like, then, you have an “open table” so it’s easy to do a reservation into one of these programs. And then you have feedback, so you can hear from the consumer what they thought about the program. We think that community health is ripe for an integrated telephonic approach.

 

I believe telehealth needs to integrate into—become an application if you will—on the EMR (electronic medical record) operating system. And I heard you comment that you thought maybe an even better place for telehealth to integrate would be the health information exchange systems, where data is coming in and out between partnering systems. What would that look like from your perspective in terms of how we’re taking care of people at a distance?

Today at Dignity we’ve invested in the solution Mobile MD, a bidirectional health information exchange. When a patient has a lab test at Dignity facilities, we push the results back into the office for the patient. When a patient goes to Sutter’s emergency room [in California] or is admitted to the hospital, [the facility] pushes the information to us and we put it on what we call the community view. So you [as a doctor] can see that your patient has been to 2 other hospitals; you can see that she’s been to 3 specialists. You have that information in the health information exchange in your office. So what we’re proposing with Mobile MD is that when you sign on to your EHR in the morning, you get a pop-up that says you have a message—your lab results, your care prints from your care managers, [a note that] your patient went to a Dignity facility [or] a Banner facility. It gives you this additional information. It could also be a patient who went to CVS, one who went to an urgent care clinic or had a telehealth solution in a skilled nursing facility. If we could connect the information through a health information exchange, then you only need to connect once to the EHR.

 

To me, what the technologies say is that I can interface with any EHR. But in Arizona alone, we have over 250 instances of electronic health records. If each interface costs $5000—and keep in mind there’s $5000 on the vendor side to interface and $5000 on the EHR company side to interface—and each EHR tries to interface with every single vendor that’s out there, we’re going to have chaos. So if we could find a way to centralize it in the information exchange, so people can see the information and pull the information, I think that makes more sense than connecting every plug.

 

I think most of us in the telemedicine world are worried about work flow, which is often a care transaction for the physician interacting with the patient, but what you’re suggesting is that we need to see the patient’s journey across the continuum between clinic, lab, hospital, where I understand all of those pieces of information so I have a better perspective.

Exactly.

We’re at a worrisome time here. What do you think will happen to hospitals if they fail to invest in the technical resources, and frankly, the change management—their cultural change—to go at risk?

This is a conversation I have with Dignity Health often because it is costly to invest in this change. This is not an infrastructure that we have in place today. We’re hospitals. We have joint ventures with other providers along the care continuum. But if we don’t align with our physicians, if we don’t align with risk, what’s going to happen is the physicians are going to align with someone else. And what does that someone else do?  Well, in California we see the physicians join a, say, independent practice association. Then they go into a market and they say, okay, Loma Linda, if you will charge me 80% of Medicare, I’ll bring my patients to you. And then they go to Glendale and they say, if you charge me 80% of Medicare, I’ll bring my patients to you. But they only get one, so whoever’s the low man, that’s where they’re going to bring their patients to. So now the hospitals become a commodity. They’re just competing on who can offer the lowest price and [still] survive.

 

Well, after a while, so much of your business is below your operational cost—so you cover your variable cost, okay, but you don’t cover your fixed cost—you can’t stay in business if you continue to constantly erode your reimbursement.  Keep in mind, Medicaid already doesn’t cover a lot of our variable costs. Medicare covers our variable costs but nothing towards our fixed costs. Commercial today does cover both your variable and fixed costs. So when you get into these situations with risk fields, the physicians are going to align where they can have more control over these healthcare costs.

 

I also think hospitals need to—seriously—quit doing services that hospitals shouldn’t be doing. Things like elective outpatient surgeries that can be performed in an ambulatory surgery center; high-tech radiology that can be done in a free-standing radiology facility; admissions that would be better cared for in the home setting with home health care or even in a skilled nursing facility. What’s going to happen is some hospitals should close wings, some hospitals should close, some hospitals should convert to services that are needed—we don’t have enough substance abuse or psychiatric facilities. We should start thinking about how we align to meet the population’s needs rather than our needs.

In a time when healthcare is really a business, what I’m hearing from you is how to create something that aligns with mission, vision, and values. And a lot of these concepts—offering unique services at particular hospitals, doing what we do best, taking care of the under-served—I really applaud you in this effort. I certainly hope Dignity and other systems listen carefully to some of the advice you’re offering. Thank you very much.

Thank you for your time, Alan.