#3 – Powering Better Healthcare: Inside WakeMed Key Community Care’s ACO Model

Host Robert Shaw talks with Dr. Roger D. Israel, Chief Medical Officer for WakeMed Key Community Care (WKCC), an accountable care organization (ACO) formed by WakeMed Health & Hospitals and Key Physicians. Dr. Israel shares how WKCC engages with its independent physicians, high-value specialists and payers to deliver coordinated, highest quality care at a lower cost to more than 200,000 patients across the Triangle. 

They discuss how WKCC leverages data analytics, referral management tools and dedicated care managers to reduce hospital visits, improve patient outcomes and support providers. Dr. Israel offers his vision for the future where ACOs become the standard model for delivering care to all patients in North Carolina.

Host - Robert Shaw, Partner, Smith Anderson
Guest – Dr. Roger D. Israel, MD, Chief Medical Officer, WakeMed Key Community Care (WKCC)

Smith Anderson is a full-service business and litigation law firm serving regional, national and global companies. Our team of experienced health care lawyers are committed to guiding medical professionals, hospitals, health care facilities and industry organizations through the attendant changes and evolving regulatory environment. We advise on health care policy, legislative advocacy, executive strategy, mergers and acquisitions, privacy and data security, litigation and the complex business requirements of organized medicine. We have been integrally involved in launching innovative health care delivery initiatives such as clinically integrated networks, joint ventures between health systems and practitioners, Community Care of North Carolina and Accountable Care Organizations (ACOs) nationwide.

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Transcript

Hello and welcome to Pulse on Carolina Health. I am your host Robert Shaw. I'm pleased to welcome Dr. Roger Israel, Chief Medical Officer for WakeMed Key Community Care, a clinically integrated network of independent physician groups, WakeMed Hospital, and WakeMed Physician Practices. 

Dr. Israel is a longtime leader in WKCC and in ACO innovation in general. We're thrilled to have him. Dr. Israel is on our podcast today to discuss how WKCC engages with its providers and stakeholders to provide the highest quality care at a lower cost, which is the goal of accountable care organizations. 

Welcome, Dr. Israel. Thank you, Robert. Glad I could have a chance to come and enlighten all about what we do here at WKCC. 

For sure. First, before we get started with WKCC, tell us a little bit about yourself, how you got into value-based care, your medical background, and what brought you here. Sure, be happy to. 

So I'm a practicing internist in Raleigh, North Carolina, at a multi-specialty group. I've been with that group for 21 years now, been a practicing physician for over 35 years now. And one of the things that becomes very apparent as a PCP is that seeing a patient once, twice, maybe four times a year, doesn't really treat the patient. 

It may make a plan, it may have discussion, may get some ideas of what's going on with a patient, but it takes so much more to actually make patients healthy. So I started looking into what else could be done to help patients feel better and be better and stay healthy. And that's where this new model of the accountable care organizations really came into play. 

WKCC was formed back in 2014 as a joint venture between Key Physicians, which is a large IPA group, and Wake Med Health and Hospitals because they knew also that more needed to be done in the community to help patients thrive. And this was a good way to kind of get everyone partnered and working together for a similar mission. And so I became involved in it in 2019, right before COVID hit, which was quite the experience. 

And it was actually a phenomenal growth experience. During COVID, the ACO was able to do so many things to help our providers survive. We had numerous educational programs, we coordinated vaccination clinics, we provided financial assistance to practices to get them through. 

So it was an incredible demonstration of the power of what a larger organization could do, more than myself as an individual provider seeing a patient. So since that time, I've become the chief medical officer and continue to work with our providers and stakeholders to make patients healthier. Right. 

So I guess that describes, that's why we have the name Wake Med Key Community Care. So it's a joint venture of Wake Med, the hospital, Key Physicians in the IPA, and it's engaged in community care. So as we go through, we talk about WKCC, that's the acronym for Wake Med Key Community Care. 

Help us with the size of WKCC, how many providers are in it? What's the scope? Sure. So we're actually quite a large ACO. We have 4, excuse me, 580 primary care providers. 

We have a wraparound network of about 1,500, what's called high value specialists that work with us. We manage about 200,000 lives in the Triangle area of North Carolina. Great. 

And what's the geographic footprint approximately? As you know, WKCC is mostly located in the Triangle region of North Carolina. So that's mostly Wake County, which includes Raleigh and the surrounding towns, and also some in Durham County. But we have practices as far north as Rocky Mount, as far west as Asheboro, and as far south as in the Sandhills region. 

So we have a pretty good geographic range in all, but the majority of practices work in Wake, Johnston counties. And when you hear the term ACO, Accountable Care Organization, what comes to mind for you? How would you describe what an ACO is and how WKCC sort of fits into that category? Yeah. Well, you know, the ACOs are created with the Obamacare Act, the Affordable Care Act, and it was a model based out of Massachusetts. 

And the concept was, is that prior to ACOs, the ability of providers to work together in a way that allows them to coordinate care and work for the greater good was being impeded by a lot of Stark and other antitrust regulations. So that this new model has allowed provider organizations to work for the greater good. So everyone can put their individual economic issues and financial issues aside and say, we're actually going to work as a group in order to provide the best quality care for the least cost at the right time in the right location in order to achieve what's called the triple aim. 

Now, some people call it the triple aim of trying to make a population of people healthy and not focus just on any individual individual in the population. And how do we do that? We want to get better quality outcomes at a lower cost. How do we create a system that incentivizes that? Is that a relationship with the payer? Is it a relationship with our providers? How do we put that goal into practice? Yeah. 

So what we've done at WKCC is we have worked very hard to engage our providers. So we work with our providers almost on a daily basis, but through our population health team, through our care management team, through our data analytics team, in order to get the providers on board with this whole concept of value-based care. Most providers grew up in essentially a fee-for-service world, where basically is you do whatever you want, you just get make money for doing it. 

And it's not really based upon, well, what really works best? How can something equally or even better quality be done, but not have to spend and duplicate services that are already been done? How can we keep that patient out of the emergency room, out of the hospital, and manage them proactively instead of just waiting to collect money on the back end? So we work with our providers. We use several vendors, which we'll get into a little bit later, that provide assistance and insight and information that we can share with them in order so that they have an idea of what does it really cost to manage a patient? What are the things that really make a difference in terms of patient's health? And what can we all do collectively to create a good financial structure to help support the activities of the primary care physicians? And what kind of vendors do you work with? Okay, so we work obviously with the payers. That's the primary source, because they're the ones footing the bill, essentially. 

So we work with all the payers. We do mostly commercial contracts. We do have some Medicare Advantage contracts. 

We have been in Medicare MSSP in the past, but not currently. But we work with the payers on developing these value-based care contracts that allow providers that are doing well to share in some of the savings that take place by doing the right care at the right time at the right cost. So that's one of our main third-party vendors is really all the different payers. 

We also use an informatics system called Arcadia. And what Arcadia does, it ingests all the EMR information from all of our practices and all the payer information and gives us a much more global understanding of what the costs really are to manage a patient. You ask an average provider how much it costs to manage a patient, they may tell you what they have charged, but they have no clue what a specialist is charged, what a pharmacy is charged, what the hospital is charged. 

They have no idea what the real costs are to manage patients. And they certainly don't know what's the difference between sending to an orthopedist on the left side of the road or the orthopedist on the right side of the road. There's often tremendous differences for similar quality or actually even worse quality, pay more for less, out there. 

So getting all this data allows us to present it to the providers to understand exactly who is the highest quality, least costly specialist or site of service in order to get the patients best managed. The third vendor we tend to use a lot is something called Proficient Health, which is a referral management platform. And it allows us to track and understand referral patterns within our ACO. 

So this is a mechanism where our primary care providers can be up to date on who are the low-cost, high-performing specialists out there as the site of referral, but it also works on the reverse end. It requires those HVS specialists to make sure that they're getting patients seen in a timely manner and that whatever information comes out of that meeting is properly sent back to the PCP to keep everybody in the loop. So coordination of care is very important. 

And then the fourth vendor, which is more an internal vendor, is our care management system. So we actually have dedicated care managers that work with high-risk or high-need patients in order to provide a lot of the extra services that an individual practice just cannot. And that provides a lot of savings and a lot of reduced ED and inpatient utilization because patients show up in the ER because they just can't get in with a provider or they have a problem and they just don't know what to do or they can't afford to get their medicines and they don't tell their providers. 

There's a lot of waste in the system that our care managers are able to help them. So that way they don't have to overuse healthcare expenses. Mm-hmm. 

I imagine you as a chief medical officer often working with the member practices on how they engage with high-value specialists and how they improve that patient flow throughout the healthcare system. Tell us a little bit about first, what is a high-value specialist? That's sort of a term of art we have here. And then how do you use the referral management system, Proficient Health, to increase that coordinated care in the clinical access? So we use a vetted network. 

So specialty groups that want to be part of our high-value specialty group actually have to apply. They have to meet certain criteria. They have to have letters of recommendation and they have to be willing to conform with our core requirements. 

And those requirements include meeting attendance. It includes doing referral management through our referral platform. It requires them to submit quality measures. 

So we have quality measures for all of our specialists to ensure that they are doing high-quality work. Obviously, cost data analysis. And then, which is really very unique, I think, for WKCC is we require not only our primary care doctors, but also all of our specialty groups to do what are called PDSAs, Plan, Do, Study, Act, Quality Improvement Projects. 

And we work with every group in our network, both primary carers and specialists, to help them figure out where their weak points are. What are the things that they could do better and help them develop internal systems to improve their performance? Some practices do great at one thing and another practice may do terrible, but all practices can learn from every other practice. And this is our mechanism of trying to spread the love. 

And you mentioned meetings. What kind of meetings are providers engaged with and attending and participating? Yeah, exactly. So we have multiple meetings throughout the year. 

So on the primary care side, for the providers, we have what are called pod meetings. So what we do is we do it on virtual now. It used to be done in person, but now virtual. 

But we basically bring in updates on what's happening in the world of value-based care. We generally will bring in outside speakers to talk about important subjects, such as asthma management, we did recently, all the COVID stuff. We did a long series on burnout to help providers during the COVID times. 

We bring in speakers to talk about heart failure management and all these pieces of information to help providers stay up to date on the best ways to manage patients in a cost-effective manner. We also have what are called all-provider meetings. We have two of those a year where we talk about the financial aspects of it, what the contracts are, what's happening in the marketplace, what is WKCC doing in helping them to create shared savings opportunities and stuff like that. 

So that's all on the provider side. We also have monthly meetings with the practice managers because for the most part, providers don't really run practices. It's their practice managers that really do all the legwork to make value-based systems work. 

So we actually have monthly meetings and it is a core requirement that they attend these meetings to make sure the practice managers are all up to date on what needs to happen to run a value-based system, how to get these quality metrics done and submitted properly to the payers so they get credit for it, and how to look for their high-cost patients and high-risk patients to understand the risk adjustment factor or RAF coding aspects of patient care and stuff like that. So we have provider meetings. So they're all practice engagement meetings so that all the practice managers attend those kind of things too. 

We have a very similar model on the specialist side. They don't have quite as many meetings, but they also do have pod meetings and provider engagement meetings and we have an annual specialist networking meeting that we have all the specialists come to. So we try to stay in their base as much as possible without hopefully overdoing it so that they understand that WKC is their partner in all this. 

We're trying to help them do a better job taking care of their patients. So we talked a little bit about data analytics and that's the Arcadia system in terms of evaluating how practices and high-value specialists are performing within a clinical, with clinical metrics as well as cost metrics. We talked a little bit about the referral management system for Efficient Health. 

And then you also mentioned the third leg of the stool, which is care management. Help us with what that is and how that contributes to integrating care and providing a better patient experience. Sure. 

So we have nine care managers. They work in teams of three and it's usually an association of a nurse, a licensed clinical social worker, and a patient advocate or sponsor. And they work together to look at who are the high-risk patients. 

So who's had an ED visit, who's had an inpatient visit, who has been on numerous high-cost medications or have had numerous referrals to multiple specialists. So patients that seem to have a very high need to be addressed that we know an individual practice or practitioner probably can't address all these things. So they reach out and make contact with these individuals and they have a pretty good adoption rate. 

They only have about a 10% declination rate. So people who won't engage, most people are very happy to try and engage because they all know, going to the emergency room is not a fun thing. So there's people out there that can help stop them from having to do that. 

They're usually pretty well engaged. And we hear wonderful stories all the time from our case care managers about how they've been able to help them. They've helped patients with suicide. 

They've helped patients get their medicines. They've helped patients get food. They've helped patients get transportation. 

They've helped patients get involved, get into their doctor's offices and stuff like that. They do whatever it takes to get that patient through the healthcare system in as efficient a manner as possible. And what we have shown through our data analytics, that if we look at the six-month period before care management and what the costs were versus their costs for the six-month period after care management, it's the same as about $1,600 per patient. 

So it's very impressive how much care management works because patients normally, they don't know where to go. They don't know what to do, but they know they need help. And this is a mechanism for giving them the help that they actually need. 

And that is the wonderful thing about population health management is you're there to take care of everybody in a group. It's not you as an individual provider in an office with an individual patient. It is an organization that's designed exclusively to help the entire local population. 

And so we talked about before we got started on the recording, the hot topic of the day being AI and the potential for artificial intelligence to really insert itself in a meaningful way here. We're thinking about connecting these tools. You have the data analytics system. 

It already does this a little bit in terms of what we call risk stratification, I guess, identifying which patients are at most risk. I think there is an opportunity there for an AI company to sort of supercharge that even more to pull out patients that we think have the greatest chance based on all the different touch points and data from the various EHRs and other sources of data. They're most at risk for a heart attack or most at risk for whatever it might be that might be an adverse outcome. 

And to funnel that information to the care manager and say, look, these are the ones that we have to focus on because all of our data points are suggesting these are the people that we need to engage with the most. I know you're doing that a little bit. I can see that could be a definite opportunity. 

Yeah. The hardest thing in population health now is that a lot of the data we work with is retrospective. So payer data basically is three months behind. 

If a person's already been in an emergency room, you've missed the opportunity to keep them out of the emergency room. If they've already been in the hospital, you've already missed the opportunity to keep them out of the hospital. So what I hope the AI will be able to allow us to understand is who is the rising risk patient? Who is that patient who is starting to do worse, but it's not at the point that they've been using healthcare services like EDs and inpatient? That there's that opportunity, that short window of time that we could intervene and keep them from having a bad outcome. 

That's the group that I hope the AI will be able to help us figure out. Who is that rising risk patient that I need to get in my office sometime this week or get a care manager involved in order to keep that patient from having a bad outcome? It seems like an ACO is uniquely suited to engage with that challenge. It's hard for a primary care practice with its own source of EHR data to make that prediction. 

It's hard for a hospital. You put them all together with the specialists and you have a large data lake with all of these touch points and you have a much greater chance of crunching through that complicated question. Correct. 

Exactly. Because there is no one source of truth and you have to look at all sources and put it together to understand the whole picture and include SDOH information and lots of other things in order to see what the population really is at and what a potential rising risk patient would actually look like. When you're working your day and you're seeing 21, 23, whatever number of patients a day, it's hard to focus on all that. 

It's not that you don't want to. There is a lot going on and stuff like that and you have limited resources within any given practice. This is kind of the wraparound shell that actually makes the healthcare system actually work for people. 

What do you think WKCC does best? I think what we do is we support our providers. We are there to help the providers to give the best care they possibly can to their patients. That's really always been the focus. 

It's really provider support and that's what we normally try to structure all of our programs around because we know if the providers are able to do their job, everyone benefits. The payers, the practices, and the patients are all going to benefit when the providers are well supported. Last question for our podcast here. 

What do you think value-based care will look like in North Carolina, say, 10 years from now? What's the future look like to you? Yeah. Well, I think everyone pretty much understands that fee-for-service cannot be the long-term model. It's got the wrong reward system. 

It doesn't align with what good health for a population really needs to be. My vision would be ACOs are not only going to be part of the solution, they will actually be the standard of care for all patients, that all patients need to be involved in some kind of population health management. You can't just cherry-pick an MA population or a Blue Cross population. 

It needs to be all the population needs to be intertwined into an ACO model that's adequately capable of providing the data, the care management, the assistance across the board. Any individual in this state should have access to the highest quality care at the right place at the right time. It should never matter what insurance you do or don't have. 

That's what I would imagine the future of ACOs ought to be, is the standard of care for all patients. Well, Dr. Israel, thanks so much for talking with us today. We really appreciate it. 

Oh, you're so welcome. Thank you, Robert. We hope that you enjoyed the podcast. See you next time.