Volume 1, Issue 2 – April 2019

1 It Takes a Partnership: CINs, PHM and the Quadruple Aim

friends raising hands together

Dignity Health’s Population Health Management program is focused on accomplishing the Quadruple Aim, which transforms health care for our patients. Our clinically integrated networks (CINs) and accountable care organizations (ACOs) are essential to the mission of improving health care quality and patient satisfaction as well as lowering costs. Here’s a glimpse at what that entails.

Participating in value-based agreements (VBAs). Shifting from a traditional fee-for-service payer model to a value-based model focused on health outcomes can be challenging. A payer, which can be a commercial insurer or the federal government, assigns individuals to a CIN based on their primary care doctor. The CIN is then responsible for providing quality care with specific measured outcomes for those patients. Our CINs work with Population Health Management to fulfill the requirements of our VBAs.

A spirit of collaboration. By working together as an aligned physician network, our CINs and ACOs are able to take advantage of sharing resources. Those resources include thing like data and analytic tools that identify high-risk patients and gaps in care that would benefit our patients if closed. Those shared resources also include care management, quality nurses and physician executive leaders. Sharing resources allows us to manage the complexity of health care and help more patients in the communities we serve.

Focusing on the whole picture. Achieving the Quadruple Aim and hitting the goals for shared savings through the various VBAs requires our CINs to achieve various quality measures, and patients must be satisfied with their care. At the same time, our CINs and ACOs look at the whole picture of care — including cost triggers like ER visits and specialty drugs — to be as cost effective as possible. If one leg of the stool is missing, it doesn’t work (and shared savings are not realized).

Commitment to the model. Dignity Health is committed to the CIN model and to value-based care. Combining our eight CINs with 11 CINs from Catholic Health Initiatives (CHI) will give CommonSpirit 19 CINs with approximately 2.2 million value-based members. Our strategic plan includes a goal to have around 75 percent of our contracts be value-based contracts in the next decade.

What about provider satisfaction? Improving the experience for providers is a critical part of the Quadruple Aim. The support for practicing physicians and allied health providers offered by our CINs and ACOs add value to practices by assisting with the management of complex and high-risk patients. Many parts of Dignity Health have participated in a recent pilot of a commercially available self-assessment tool, WELL-BEING INDEX. Our providers are critical to our success, and we are working with our CINs to ensure we don’t miss this part of the Quadruple Aim.


2 What’s an ACO Anyway?

Accountable care organizations (ACOs) are groups of doctors, hospitals and other providers who come together voluntarily to deliver coordinated high-quality care to their Medicare patients. The Medicare Shared Savings Program (MSSP) encourages the creation of ACOs to help ensure patients get the right care, at the right time, avoid unnecessary duplication of services and prevent medical errors. When an ACO succeeds in delivering high-quality care and spending health care dollars more efficiently, it shares in the savings it achieves for the Medicare program.

For 2018, Dignity Health had five Medicare ACOs with nearly 100,000 lives attributed to them.

  1. Southern California Integrated Care Network MSSP (California)
  2. North State Quality Care Network MSSP (Northern California)
  3. St. Rose Quality Care Network MSSP (Las Vegas, Nevada)
  4. Arizona Care Network MSSP (a jointly owned clinical integration network between Dignity and Abrazo Health, Arizona)
  5. Arizona Care Network NextGen (a jointly owned clinical integration network between Dignity and Abrazo Health, Arizona)

3 Get to Know GPRO

Young girl enjoying outdoors
Between January and March, our five ACOs engaged in the Group Physician Reporting Option (GPRO), the process of abstracting and validating quality data for Medicare Shared Savings Program (MSSP).

The GPRO Process

  • CMS provided Dignity Health with patient lists for each of our participating CINs. Once received, a team of abstractors spends up to eight weeks abstracting the required data from the athenahealth platform.
  • For each CIN in the program, we are given 616 beneficiaries for which to pull data, with the expectation that we report back — validating in each chart that certain measures were met — on a minimum of 248 consecutive beneficiaries for each measure (or 100 percent if we have fewer than 248 eligible beneficiaries). A beneficiary was assigned to the ACO if he or she had at least one primary care visit with a participating provider during a specified timeframe.
  • Last year, of the 31 quality measures required by MSSP, 15 had to be manually abstracted from patient charts. The rest came from patient satisfaction surveys, utilization and claims data and other sources. 

What We’ve Learned

  • Reviews of the data show our participating networks exceeding the national MSSP average in many of the measures.
  • Even more importantly, through the abstraction and verification process, we now have reliable benchmark data to assess the performance of our networks, practices and providers.

Moving forward, network leaders and individual providers will be able to view their quality data to determine where improvement is needed in processes or reporting. Learn more in the 2018 Population Health Value Report.

4 New Toolkit Offers a Roadmap for Future CINs

Senior Mexican Woman Working Out

As Dignity Health evolves from a hospital to a care continuum company, we’ll continue to establish clinically integrated networks (CINs) and ACOs with community providers. Because the process of creating and operating a CIN is complex, the Population Health Management team has developed a CIN Toolkit to provide a knowledge base of tasks, activities, documents, technologies and communications required to ensure success.

The new toolkit includes checklists, resources, examples, templates and a repository for CINs to upload and maintain their documentation. It is structured to support the life cycle of establishing and operating a CIN, and includes phases — Pre-Work, Strategy, Design, Implementation and Review/Follow-up — where specific activities and documents are required as well as areas of focus, which allow subject matter experts (SMEs) to work directly in their area of expertise, from marketing and finance to care coordination, technology or education and training.

5 Did You Know?

Dignity Health GPRO by the Numbers: 2018

  • ACOs in MSSP: 5
  • Abstractors: 34
  • Man Hours*: 13,400+ (*Does not include administrative duties)
  • Total Number of Beneficiaries Abstracted: 14,300
  • Total Number of Measures Abstracted: 41,901
  • Time to Completion: 6 weeks

6 Meet the Pop Health Team (Q&A)

Kelly Bitonio

Get to Know the Team: Kelly Bitonio, Director of Ambulatory Quality

Our Population Health Management team relies on expertise in various disciplines. Kelly Bitonio, Director of Ambulatory Quality for Dignity Health, is one of our leads for quality measure selection, collection and reporting within all of the CINs.

Her role is to ensure the integrity of our data, that we’re able to collect on all measures, to report on them in a timely fashion, and to use the data to help make performance improvements and make a difference at the patient level.

What is it about population health and our mission that resonates most with you?

It’s the potential to make a huge impact. I was in the Army as a nurse, and I worked as a clinical nurse in the ER. I know we’re not going to improve a population by putting a band-aid on the things we see in the ER. We have to reach people way before they arrive in the ER. Of all the roles I’ve held, from staff nurse to chief nursing officer, my favorite focus has always been quality because of its deep impact.

What makes you proud to be a part of Dignity Health?

I’m excited that we’ll be taking care of 1 in 4 people. I believe in our cause and our systems. I chose to work for Dignity Health because its mission and values resonated with me, and it’s been the best decision I’ve ever made. So to further that mission is very exciting to me.

What do you like most about your job?

My favorite thing is the collaboration, and being able to make sure the people providing the care know why they’re doing it. If you know why you’re doing something, you do a better job.

Everyone is so busy and trying to be efficient that they can become task-oriented and may not think about the “why” behind what they’re doing. That means, for example, thinking about how you’re ensuring someone gets their cancer screening so they can catch something early and be able to see their children grow up, versus just being focused on our overall cancer rates.

What are you most proud of in this role?

I think what I’m most proud of right now is the stronger relationship we have with our foundation and the community physicians we didn’t have five years ago. I attend the boards and town hall meetings, and I think the collaboration we now have is incredible. Even though we’re in different CINs, we’re all working toward the same goal. Establishing those relationships and the connectivity between the different CINs and the groups within them has taken a lot of footwork, consistency and persistence over time, and I’m proud to have been a part of it.

You’ve seen the full evolution of population health management. What are you most excited about?

I think the thing I’m most excited about is that people are now being more aware that the work for our patients doesn’t have to happen in the hospitals; more of it can happen outside. I’m also excited to join with CHI and be CommonSpirit Health. Together, we’ll be able to have a broad range of outreach programs, and if we can incorporate that along with the data and the process improvement, it’s going to be an awesome thing. I know we’re moving in the right direction.

How do you spend your time outside of work?

I love to travel; one of my personal bucket list items was participating in a medical mission, and I did that in Fiji two years ago and it was a very eye-opening experience. I also love spending time with my family and especially my grandchildren.

7 Final Word

“Population Health Management has to be a physician-run solution; this cannot be an administrator telling physicians what to do. Physicians know what to do; they just need assistance to help the patients. Our population health management solution is run by physicians and, since the beginning, any of our decisions, such as clinical pathways, are defined by physicians.”

Julie Bietsch, Vice President, Population Health Management

8 Our Mission

Our mission is to provide health care that improves the well-being and quality of life for the individuals and communities we serve.