This interview with Lisa Trumble is mostly about clinically integrated networks (CINs)—what they are, how they work, how data get shared. Furthermore, we talk about hybrid CINs, meaning, for example, a virtual front door that might lead to in-person care. After that, we talk about the potential impact of direct contracting, which Lisa says could significantly change the healthcare marketplace. The hybrid talk, by the way, is toward the middle of the show; and we talk about direct contracting—that’s near the end if you’re short on time and you want to skip around.
But before we go there, let’s just level set a little bit, shall we, on the topics of accountability and integration as general constructs. Specifically, what’s the impact, or lack thereof at times, when the provider is not accountable for patient results? I’m talking here about fee for service, in general, where the provider is not accountable for patient results.
Like, if we’re talking about a fee-for-service world and what it incents, it goes like this: Transaction happens. Somebody sends a bill. The end.
I mean, in a fee-for-service world, the patient encounter may be the highest- or the lowest-value patient-doctor transaction in the history of humankind; but either way, the payment is the same. So, the incentive is to figure out how to encounter lots of patients and/or upcode wildly, I guess. The incentive is not to coordinate care or teach a patient how to take advantage of a telehealth offering to mitigate some social determinant of health or spend 10 minutes doing some education or shared decision making or establishing rapport and being culturally sensitive. Any docs who are doing that stuff are doing it on their own time in an FFS world.
Here’s the good news and the bad news—and I don’t often hear it spelled out this bluntly, so I’ll do the honors: If anyone wants to get paid to create patient health, they have to be accountable for the outcomes created—upside and downside. Frankly, when an organization is super worried about the downside, that could be—not in all cases, but it certainly could be—a clue that maybe their approach is a little bit more transactional and/or inefficient than perhaps they would like to admit.
There’s been much talk over the years about the importance of giving patients so-called “skin in the game,” but what might work out better is to mandate that providers have so-called skin in the game. Providers have to be accountable so good providers can reap rewards and bad ones don’t. The episode with Sunita Desai (EP334) is all about how providers have proven to actually be better “consumers” than “consumers,” so there could be a constellation of rationales here.
Now, if you’re accountable for care, you must actually create outcomes, as just discussed. And to actually create outcomes, there must be integration. Integration is necessary. Care coordination is necessary both with internal and external other providers and entities. There are very, very few cases where a chronic condition can be appreciably improved by a random assortment of 7- to 15-minute patient encounters. Managing chronic conditions requires a longitudinal journey that weaves together most often more than one doctor, also nurses and a PA and a speech pathologist and a nutritionist and a Certified Diabetes Educator and maybe a physical therapist or two. Considering that 85% of healthcare spend in this country has to do with chronic conditions also ... yeah, integration is really required. And, yeah, how many decades later, we’re still talking about interoperability.
Here’s a tidbit I found kinda apropos: Female doctors make $2 million less, apparently, over a 40-year career than their male counterparts. That’s per research in Health Affairs, recently reported in the New York Times. More men become surgeons, and women have been shown to spend more time with their patients, leading to fewer services that can be billed for.
What’s the actionable takeaway there, I wonder?
In this healthcare podcast, I have the honor and pleasure of speaking with Lisa Trumble. Lisa is president and CEO of a CIN, a clinically integrated network, called the Southern New England Healthcare Organization, or SoNE. SoNE was formed in January 2020 to integrate three ACOs [accountable care organizations] in two states. The CIN manages a population of over 200,000 patients—about $1.5 billion in total costs of care. Previously, she worked at Cambridge Health Alliance building their pop health and value-based structure to the point where about 60% of their business was in some form of risk or alternative payment models.
There is one disclaimer that I would just ask you to keep in mind when listening to any conversation about value-based care—and there are lots of them going on right now—but I just want to tuck this in here because I’d be remiss not to mention it at some point. Dr. Mai Pham (EP325) has put this better than I ever would. She said recently, “After a decade of value-based payment contract negotiations in both public and private sectors, I would like to point out that [health systems] can talk a good value game, but if their ... organizations push for ever-higher unit prices, the word value is meaningless. I’ve seen trends in unit prices for a given health system outstrip the legitimate savings it produces by reducing volume, which was the plan all along.” Dr. Pham is currently writing a piece about this exact topic that’s going to appear in AJMC soon, so definitely look out for that.
You can learn more at sonehealthcare.com.
Lisa M. Trumble, MBA, president and CEO of SoNE HEALTH, has had a career showcased by successes in generating strong clinical and financial operating results for healthcare organizations. She has 30+ years’ experience at integrated delivery systems and physician organizations. Prior to joining SoNE HEALTH, Lisa served as senior vice president of accountable care at Cambridge Health Alliance (CHA); the scope of her responsibility included systemwide duties for accountable care and population health management, incorporating payer contracting, financial medical economics, regulatory compliance, and administrative and clinical programming. Under her leadership, the organization realized significant improvements in clinical and financial outcomes.
Lisa joined CHA from Berkshire Health Systems, where she served as vice president of physician services and executive director of the Berkshire Health Systems Physicians Organization. She was instrumental in transforming physician operation, restructuring provider employment agreements and provider compensation plans, and enhancing patient satisfaction. Prior to Berkshire Health Systems, she served as the vice president of finance and operations at the Cambridge Health Alliance Physician Organization, where she achieved similar outcomes.
Previously, Lisa was administrative director for anesthesia and surgery services lines at North Shore Medical Center and chief financial officer of North Shore’s Physicians Organization, a subsidiary of North Shore Medical Center. Additionally, she held positions in operations and finance at Commonwealth Health Management Service and Independent Physicians Association. Lisa holds a bachelor’s degree in business administration from North Adams State College and a master’s degree in business administration and healthcare finance from Western New England University.
06:20 Why do accountability and integration go hand in hand?
08:56 “Aggregation just for the point of aggregation doesn’t necessarily produce better outcomes.”
09:18 What questions should we be asking when considering aggregation?
09:45 Does aggregation equal integration?
11:42 What exactly is a clinically integrated network?
12:26 What is the intention of a clinically integrated network?
13:22 Are all CINs ACOs? Are all ACOs CINs?
17:22 What entities make up a clinically integrated network?
19:26 “We want providers that are able to generate the outcomes that we’re expecting.”
20:44 “There is a lot of work that goes into data integration.”
23:14 What is a hybrid CIN model?
25:22 Encore! EP206 with Ashok Subramanian.
26:53 “Everyone is sitting around the table proactively.”—Stacey
29:37 What kind of structure could move the Medicare market quickly?