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Gregg Masters 00:06
This is PopHealth Week on HealthcareNow Radio. Today’s episode is sponsored by health innovation media. We bring your brand messaging alive at major trade show conferences and innovation summits connect with us at www dot pop up studio dot productions. I’m Gregg Masters Managing Director of health innovation media publisher of ACOwatch.com and your PopHealth week co host with my partner co founder Fred Goldstein, the president of Accountable Health, LLC, a Jacksonville, Florida based consulting firm. Our guest today is Jeff Rideout the president and CEO of the Integrated Health Care Association, also known as IGA, a California nonprofit organization representing health plans, hospital systems, physician groups and other healthcare stakeholders. Dr. Rideout is responsible for management of all IHA programs and activities, including its nationally recognized pay for performance program performance measurement and payment innovation initiatives and efforts to enhance the adoption of health information technology and improve health care affordability. Prior to joining IHA, Dr. Rideout was the senior medical advisor for Covered California, supporting clinical quality network management and delivery system reform related to the 1.1 million Californians enrolled through the exchange. Today we discuss the Symphony Provider Directory project, a clearinghouse of sorts that maintains up to date information about provider participation in health plan networks, a challenge not just in California, but across the nation. So, Fred, over to you. Help us get to know Dr. Rideout out and his work at IHA.
Fred Goldstein 01:58
Thank you so much, Greg. And Jeff, welcome to PopHealth Week.
Jeff Rideout 02:01
Thanks, Fred. Appreciate it.
Fred Goldstein 02:02
Yeah, it’s a pleasure to have you really excited about the show. For beginnings, could you perhaps give us a little bit of background on yourself your role, and IHA, .
Jeff Rideout 02:11
sure, I’m an internist, internal medicine physician by training. I also did some training in economics and philosophy. So in a previous life, I would have been called a dilettante. But I’ve always been interested in the management and policy surrounding healthcare and populations of people in particular. And so there’s a pretty natural fit between what I’ve been interested in professionally and what Iha has been trying to do, essentially, over the same period of time, IHA has been around for about 25 years, 26 years now. And really, its primary goal is to promote integrated health care, or what has more recently been called population health.
Fred Goldstein 02:50
So when you say promote population health and integrated health care, could you get into a little bit more of what specifically you do in that area?
Jeff Rideout 02:57
I think my perception of it over the last several decades, and I served on the board of IHA for, I think, four different companies. So two health plans, one large employer, one large provider group, one’s health IT vendor, so IHA ha been kind of in my blood or in the water for most of my career. And I think what I’ve taken away from both my own work and sort of the work of IHA is, there are some very important and specific things that organizations, whether they’re plans or provider organizations, or regulators need to think about when you’re taking care of a population as opposed to when you’re taking care of an individual. And a lot of I think my more formative training, when I was younger, I actually spent three years in England did some clinical work in the National Health Service, and also did quite a bit of policy work with the National Health Services major private, not for profit policy, advisory body, it’s called the Kings Fund, there’s an orientation in a lot of systems toward taking care of populations, as opposed to just taking care of individuals. And it really changes the dynamic of how people allocate resources, how they prioritize infrastructure commitments, how they are proactive, as opposed to necessarily reactive. So obviously, ideally, both things happen together, there is some proactive attention to what people need in general and what they’re maybe not looking out for on their own or what their doctor is not aware of on on his or her own. But then obviously, you also need infrastructure that can support acute care. More recently, and I think more importantly, lately, aftercare and post acute care as our population ages, and chronic disease becomes part of the landscape for nearly everyone over 65. How do we keep people healthy at home? How do we meet their needs without necessarily always bringing them into an acute care setting?
Fred Goldstein 04:52
I know, in the past years, plus, you folks have worked on a new product called Symphony. Can you talk a little about Symphony what it is and what it was designed to solve for
Jeff Rideout 05:02
sure. And it’s interesting you, you identified it as a product, which is what we do as well, that’s somewhat new for IHA as an organization. Like a lot of things, it comes as a reaction to what isn’t working in our system. And unfortunately, one of the downsides of having a purely for profit and not purely single payer system is there’s a lot of variation. And there’s a lot of opportunity for different organizations to approach the same problem in different ways. And while in many industries, that’s a great thing, and it’s drives a lot of innovation in healthcare, it also drives a lot of fragmentation. And one of the things that we’ve found at IHA is that even as large as some of our health plan members are, or even our large provider groups that some of them are taking care of millions of enrollees, they can’t necessarily solve all the problems of fragmentation themselves, even an organization as large as Anthem, or Blue Shield. And so there are some problems in the industry that lend themselves to utilities or standardization that allow people to essentially coordinate around a common platform, thus the utility concept and then as we say, collaborate on that so they can compete on other things. And Symphony was one of those industry problems that in my experience has been around forever. Really, it’s the accuracy or inaccuracy of provider directories. And directories are really the proxy for all all things about providers, you know, where they practice, what their specialty is, what health plan products they do, or don’t participate in, maybe things that go to their credentialing and their status, whether they’re retired, whether they’re currently licensed, boarded and things like that. And what has happened in California, and frankly, in every state is when you have multiple health plans and multiple provider groups of any size or scale. There’s a huge amount of opportunity for misinformation and lack of coordination across those entities. So that something as simple as what is the primary practice specialty of a physician may be different from one organization to another. And that organization might be a health plan. So different between health plans, or it might be different between provider groups where the physician is actually participating in more than one provider group. And so what Symphony really was, was a response or a reaction to very problematic and error driven provider directory information that came about as part of Covered California. And I was the first medical director Covered California and one of the goals was if you’re going to offer individuals a choice of health plan products, but they will have some financial risk and choosing one versus another or their benefits for a, you know, a platinum plan versus a bronze plan, then the accuracy of the information about the plan, including the accuracy of the provider directory is really, really important. And, you know, that was probably the first time in my experience where choosing a plan correctly really determined whether you could have access to the physician or the hospital that you really wanted to. And to cover California’s credit, the idea was if we’re going to ask people to choose, and if they’re going to have financial exposure, just like the federal exchange, then we better have a pretty good idea of what their physician and hospital choices are. The problem was the data that was coming to cover California, or that is coming to the federal exchange or is coming to any health plan from their provider can be quite inaccurate. And it’s especially inaccurate when you layer it on top of each other. So what one plan thinks is your practice address may be different than what another plan thinks is your practice address. And if you think about sort of simple mathematical principles, you kind of multiply the error rate by the number of organizations that are touching the information. And by the time you get to the end of the process, the accuracy that you could see on a combined directory, for instance, can be quite low in certain areas. So that’s kind of a long explanation. It really the short explanation is even as big and as committed as plans were the accuracy that they could generate around their own provider directories wasn’t that good when compared to other plans, provider directories or when compared to other organizations like large medical groups?
Fred Goldstein 09:15
This is fascinating. I’m thinking back to when I was running a health plan back in the mid 90s. And obviously, I was keeping up that provider directory even for a health plan just in Northeast Florida at the time, it was 10 counties was very difficult. And obviously it’s critically important for the individual enrolled in that plan or thinking of enrolling in that plan to have that information available. So I’m fascinated by this concept of you said of setting up utility that really sounds like a great concept of how to look at this as a way to solve that problem. And over the past couple years, as you will know people have been screaming pretty heavy about hey, my doctor was listed as in this network, but they’re not and I signed up for it. So this really went to the heart of trying to solve that problem.
Jeff Rideout 09:54
It definitely did and I share your vintage experience of working for a health plan where I had responsibilities for the directory, and even then it was, you know, a strong commitment. But the accuracy of the directory, there wasn’t as much pressure on the accuracy of that directory versus any other because most networks, especially on the PPO side, were quite broad, what I think came with the ACA and some of the exchanges was that people chose to tailor or narrow or whatever you want to call it, their networks. And so there became a huge premium on the accuracy of each network in comparison to one another, you know, the velocity of change within the physician community is least in California, and I think in most other states is also huge. So, and by velocity, I mean, which not just organizations they participate in, but which products within those organizations they participate in, and in many cases, they don’t even know, because there may be literally hundreds of different plan products that are offered by the same health plan, you know, in your case, maybe the Florida Blue or in my case, Blue Shield, or Anthem. And what happens is the participation in each of those can change the practice location can change, a physician could practice as a primary care physician in one network and as a cardiologist, in another and they might be trained as a cardiologist, but are practicing, you know, as primary care and another network, they may work after hours in one location, but not another. So every time one of those things changes, it triggers a potential inaccuracy in the information that somebody is seeing when they get to the directory. And of course, the historic handling of directory information was paper based. And so actually being able to keep directories current was limited by even sort of how the directories were created, let alone the information that was going into them. So any of the the idea here of a utility is everybody’s submitting their information on a regular basis using common formats and clear errors that maybe are simple like an address that says street versus Avenue. If 10 plans are saying it’s street in one plan is saying Avenue, relatively easy to double check with the one plan and say we think it’s Street, you know, can we make the change, other things get more complicated, like specialty practice open to new patients or not. But the only chance you really have of keeping up with the the change in the environment that we work in is by essentially having a platform that is constantly checking that against sort of what the best case says it should be versus what say nine out of 10 submitters are saying it is and and then doing the verification along the way.
Fred Goldstein 12:33
So this came about because of Senate Bill 137, I believe, who’s ultimately responsible for making sure that the information is correct. You’ve got the payer side are providers that and then the provider side? Where does the responsibility lie in that?
Jeff Rideout 12:46
Well, from a legal and regulatory point of view, it’s the plan the health plan. So the health plans are what are regulated by SB 137. And just for your listeners, SB 137, is, for the most part considered the most rigorous and most complicated and most detailed set of expectations around provider directory information in the country, it far exceeds what we see for Medi-Cal in California, which is rigorous in itself. And it’s far in excess of what CMS requires for Medicare and Medicare Advantage plans. So at some level, it’s a gold standard, if you want to look at that way other people, you know, see it as sort of like the ultimate hurdle. But the health plan is the entity that’s regulated. So Senate Bill 137, regulates the health plan, what we found, and we work very closely with the regulator, in fact, the state’s chief regulator is a non voting member of the IHA board, what we found is that you can create all kinds of penalties for non compliance, whether those are reasonable to enforce or not becomes a real problem, because the regulations themselves because they were a reaction to really bad information are fairly draconian, at the extreme, they would allow health plans to not pay providers or to take them out of their network. But what nearly every health plan we’ve talked to, and most of them are members said, well, that’s not really very realistic, I can’t really use that kind of hammer on my network, especially in areas where I don’t have a lot of other choices. So the idea that I’m going to remove somebody from a network and essentially create a gigantic access problem, especially in rural counties, where there may only be two or three health plans operating. That’s not very realistic. And for the regulator’s part, they understand that and so part of the Symphony platform and product was to say, how do we keep the spirit and the and essentially the intent of the regulations going while helping to solve the problem at the same time, and, you know, frankly, mitigating some of the more draconian expectations that weren’t really based in what the plans and the providers could even deliver on. So there were a lot of turnaround times that created their own kind of operational inefficiencies. So we’ve been working very closely with the regulators to Because the language of SB 137 is up for review and renewal, you know, what would make the most sense to in terms of revisions. So it’s really been a great partnership along the way.
Gregg Masters 15:11
And if you’re just tuning in, you’re listening to PopHealth Week on HealthcareNow Radio, today’s episode is sponsored by health innovation media.
Fred Goldstein 15:20
And you produced a white paper that talks about some of the initial learnings from launching the product. Can you get into some of that? And what were some of the takeaways from this?
Jeff Rideout 15:28
Sure. I think that the context of this is that part of what we wanted to do was say, look, does the utility concept offer any advantages, ultimately, and we did it in what we call the soft launch environment. And the reason it was called soft launch is, it was more than a pilot, we actually built this on a platform that that is what we’re using to scale to the entire state. So right now, we got 11 health plans and over 100 provider organizations accounting for hundreds of 1,000s of individual provider records. So the platform itself from a technology point of view was designed out of the box to really handle that level of volume and scale.
Fred Goldstein 16:08
So Jeff, how many providers were on the system during the soft launch? And how many are there now?
Jeff Rideout 16:13
Well, right now, we have about 100,000 providers, primarily physician providers, but we also have ancillary providers. And because of the way we count, that actually translates to 475,000, unique provider records, because each one of those providers generally works with more than one plan. So you know, you can do the rough math, but it’s about one to five. So we’re we’re clocking up to a very high percentage of the total number of physicians in the state. And we, you know, we look to kind of cover the rest over the next two to two to three year horizon, as we get more plans on boarded, give you an idea 30,000 of those records, so slightly, you know, seven or 8%, contained at least one major provider identification issue. And by major, we mean something that would lead someone to make an error in the selection, either in terms of location or accepting new patients are even whether they were part of the network or the right specialty. So you know, that’s the kind of thing where, you know, people need to know that level of detail. And, for the most part, what we found was that we could even in the soft launch environment, bring those error rates down by 10 to 20%, even when we didn’t have complete access to all the providers and plans working in that geography. So probably the most important things for people on the receiving end are really, is this physician actually in the network that I have access to? Is this physician accepting new patients? Is this physician located in a place that actually I can get to and is actually delivering care? Because a lot of the demographic information was more for billing purposes like a P.O. box? And is this physician qualified to practice in the specialty that they’re identified in? So you know, and there’s obviously more serious problems? Like, you know, are they currently licensed? And are they retired and things like that? So those are just some of the the numbers that we that we actually are starting, we’re seeing in soft lunch.
Fred Goldstein 18:10
And you mentioned now that you’ve, you’re scaling up? So how much of the state do you have now? Or are you already there do you anticipate getting there, at what point
Jeff Rideout 18:18
we it’s, I don’t want to say it’s hard to to quantify, but let me describe what we held ourselves accountable to we wanted over the four year horizon of the business plan that funded this program, we wanted to get to at least 80% of all plans, and the enrollees, they serve, 80% of all providers, which is a different number, and 80% of all consumers. So the notion was you can’t get all the plans, but not have the providers that that work with them. And you can’t get all the providers but not all the plans. And you certainly can’t do both, and then leave out a big chunk of the consuming population. So we’re well on our way from a contract point of view. So our main goal in this past year 2019, was to sign both the health plans and the providers that would represent that. So we’re at this point, actually over that from just who we contract with. So we have all the major network plans. In California, we’ve got 110 physician organizations, we have access to about another 30,000 individual practicing practicing physicians this year, and over the next two years, it’s really about getting all of those organizations on the platform. So we’re trying to be really honest with ourself and not saying, Look, just because we signed somebody up doesn’t mean they’re on the platform. And that’s one of the hard points for people to understand is yes, they’ve signed up for Symphony but as you probably know from your health plan experience, it can take a year to make an operational or IT change within the system even for something as simple as changing the middle initial of a provider. So We’re not it’s true, we’ve had many discussions with some plans about, we want to make what seems to be a fairly minor change that has to get in their queue that can take six months to 12 months. And so we’ve been both realistic and kind of insistent that that kind of timeframe has to change operationally. So imagine a not for profit collaborative, you know, voluntary organization trying to convince a gigantic health plan that they need to change how they prioritize IT activities. So that’s, I’m giving you sort of what makes it hard. But I think from a scaling point of view, we will we will get to our 80% over the next two, two and a half years. That’s that’s what the business plan calls for.
Fred Goldstein 20:30
That’s really fantastic. Actually, it’s a huge, what you’re doing is actually a pretty huge problem, as you’ve explained small pieces of it. Yeah, I can imagine, you know, changing that middle initial, in the end the whole system, has the health plan crashes, because they can’t pay bills anymore, because it’s something you know, right? You end up with things like that. Absolutely. So great, great progress. And what have you heard so far from those who have been involved in or in the system?
Jeff Rideout 21:07
Well it’s working? Well, we have, fortunately, we structured this around the commitments of our largest health plan and provider organizations that are on IHA’s Board, and, frankly, those that are on our Executive Committee. So the model here was we can lead this, but we can’t do it for you. So if people liked the idea, but aren’t willing to commit, not just the money to do this, but also the operational and IT change that’s required, you know, let’s not, let’s not fool ourselves, you know, we have to really say we all want to do this. And when we say we want to do this means you as an organization and a leader are going to go back to your organization say we need to do it this way. And we need to do it. So I think everybody has really, really embraced that model. And I think that’s the proofs in the in the contracting. And we had a couple of great advantages. There was an organization that’s one of our IT partners called Gain, that had been doing this at the Medical Group level for some time and and had made good progress like 60, to 65, large, very large medical groups, that part of the equation that they were struggling with, frankly, was getting the health plan signed up. So we kind of brought those two things together and expanded the physician group signups and the health plan signups. And then the third part of that is the individual physician. So not every physician practices in a group, a lot of physicians practice relatively independently, or they may practice in both, and they may be submitting their information, you know, for their independent practice, distinct from their group practice. So there’s another level of complication. So I’d say from a long winded way of saying from a, can we get everybody to buy into the philosophy of the utility and, and really commit to it? The answer is definitely yes, I would say from a soft launch point of view, the information about what we could do to improve was really, really well received, like I but I think that was balanced by the notion of we didn’t know the problem was this was as bad. You know, because most people are working in their own. I don’t want to say silo. But if you’re working for a plan, and you’ve got a network, you kind of have some sense of your, you know, this isn’t as good as it could be. But I don’t think you have any sense of how good or bad it is relative to your peers, everybody has some drops. But when you put all the drops together, it’s pretty bad. I’d say where we’re still jury’s out is can we get there fast enough to satisfy the heavy lift that it really is, and heavy lift in terms of IT and operations, also heavy lift in terms of what it costs. And we, you know, fortunately, it’s a not for profit, we don’t have to make a margin on this, but we priced it to say, look, this is close to breakeven. But if you want to do a better job, it’s going to cost more to do a more thorough job. And you know, the everybody’s holding the line, there’s no, we can negotiate a price concession because we’re bigger, you know, everybody’s like, no, and this only works if everybody feels like it’s fair. And the health plans are paying a lot of it, because we’re doing it on a per provider record. But the tension of saying, I’m, I’m happy to pay a bit more than I, then I hit was paying to do a poor job at this. You know, that’s one that is I think the jury’s still out on whether we can kind of keep holding the line on that. And I think the balance is going to be people will see the results as they see sort of what it takes to get there. And I think the quite frankly, the balance on that is the intensity of the regulations and the enforcement of that and the timeframes on that relative to what people expect.
Fred Goldstein 24:40
You chose obviously, as you said before, 75,000 providers, based on a soft launch, you chose the biggest state Yeah, you know, tons of doctors, etc. Big health plans. You obviously had a fair amount of resources to begin this have learned a bunch since then. Is this something you’re going to take or could take to other states as they begin to look at this problem?
Jeff Rideout 24:59
That’s a really interesting question, and it’s got a few wrinkles to it. So first of all, on the provider side, there are many provider organizations that work on both sides of the border, particularly around Nevada and Northern California, Oregon. So we’re not discriminating between provider organizations that want to give us their entire provider network, that would be relatively artificial, because that network may be serving people on both sides of the state. So in some ways, we’re doing that just because it’s common sense there. If you go to the information we’re collecting, and stay within California, there are other use cases, particularly credentialing information, not the peer review part of it. But the information one needs to do for per credentialing in general, where most of that we’re collecting anyway, the directory information is is very similar in terms of scope to what you need for credentialing, not not 100%, but pretty close. So that’s probably the next obvious place to go. And then the third area, a number of our plans are multi regional or national. And you know, one of the things that we’ve been dealing with, and I think it’s been hard, but we’ve been dealing with it successfully is a national plan doesn’t want a California only solutions. So are they going to adopt something that works here that doesn’t seem to apply, and then we get into, you know, competitors and things like that, that are trying to do some of the same work on a utility basis. So what we’ve decided, organizationally is, let’s get this right, for provider directory work, let’s not be stupid and cut off things at the state border, that don’t make sense. Let’s think about the information set that we’re collecting and what other uses it’s best for. And then as we need to let’s go to adjacent states where our health plans in particular are asking us to go there to make their lives simpler. But, you know, the caveat to that is, every state has its own regulatory environment. So just because it makes sense to a national plan to go to Oregon or Washington or Arizona, doesn’t mean it makes any sense at all, to the provider community or the regulators in those states. So, you know, we’re trying to be thoughtful, and not close our eyes to what we could do. But you know, also realistic about what it takes. And I would say also, the starting point on this was people really, really, really wanted us to focus only on provider directory information, you know, the theory of the case was a common platform for directory information, and, you know, performance information and data in general, why not do everything you know, then you’re kind of, you know, the platform for everything anybody could want. And the there was a really, really clear mandate that we just get this right. And I would say, knowing whether we’ve got it right or not, is still in front of us. It’s not behind us. But as we’ve shown that we can hit our milestones, people are now and by people, I mean, you know, our stakeholders and our participants, they’re starting to say, well, wouldn’t it make sense to do this as well. So I think what we’re doing is earning the right to expand, but it will be somewhat incremental. And, you know, we haven’t talked about IHS historic work. But that’s really been around performance measurement, essentially, you know, all payer claims database environment, and, you know, doesn’t take too much to think about the connections between better provider data and better performance data.
Fred Goldstein 28:25
Jeff, thank you so much for joining us on PopHealth Week.
Jeff Rideout 28:28
My pleasure. Thank you.
Fred Goldstein 28:29
Back to you, Greg.
Gregg Masters 28:30
And thank you, Fred. That is the last word on today’s broadcast. I want to thank Dr. Jeffrey Rideout the president and CEO of the Integrated Healthcare Association. For his time and insights today, be sure to follow IHA’s work on Twitter via @IHAconvene, and on the web via www.IHA.org for PopHealth Week, my colleague Fred Goldstein, and HealthCareNow Radio. This is Gregg Masters saying bye now.