2019 Annual Report · 2020. 6. 24. · Member Services ... Mike Dewerff, CFO Bryan Health - Lincoln Patrick Ganyo Bryan Health Connect - Lincoln James Griesen, PhD (Medicare Beneficiary)

2019 Annual Report

HEALTHCONNECT

Year in Review ........................................................................................................................................................................................... 1

About Us ....................................................................................................................................................................................................... 2

Mission ........................................................................................................................................................................................................ 2

Vision ........................................................................................................................................................................................................... 2

Staff ............................................................................................................................................................................................................... 2

About Our Members ............................................................................................................................................................................... 3

Provider Breakdown ................................................................................................................................................................................. 3

Governance 2020 Bryan Health Connect Board of Directors .................................................................................................................................. 4

2020 Bryan Health Connect ACO, LLC Board of Directors ................................................................................................................ 4

2020 Clinical Guidelines & Quality Assurance Committee ............................................................................................................... 4

Clinical Support Transforming Clinical Practice Initiative (TCPi ) .................................................................................................................................. 5

Exemplar Practice Story: Saunders Medical Center ............................................................................................................................. 6

Trek to Transformation: Inpatient Physician Associates ..................................................................................................................... 7

Member Services ..................................................................................................................................................................................... 8

Communications & Marketing ............................................................................................................................................................... 9

Education & Events ................................................................................................................................................................................ 10

Accountable Care Organization Annual Wellness Visits, Medical Risk Adjustment & Hierarchical Condition Coding ................................................................. 11

Medicare Shared Savings Program (MSSP) ....................................................................................................................................... 11

BCBSNE Value-Based Contract ............................................................................................................................................................ 11

Data & Analytics ..................................................................................................................................................................................... 11

ACO Operations Council ....................................................................................................................................................................... 11

Population Health Initiatives ............................................................................................................................................................... 11

Current State Assessment ...................................................................................................................................................................... 12

Clinical Collaboration Opportunities ................................................................................................................................................... 12

Annual Wellness Visit ............................................................................................................................................................................ 12

ACO Annual Meeting ..............................................................................................................................................................................12

Medical Risk Adjustment ....................................................................................................................................................................... 12

Quality Measures Review with IT Infrastructure .............................................................................................................................. 12

Table of Contents

Bryan Health Connect’s (BHC) first year with a designated chief medical officer was both challenging and productive. Our newly expanded team evolved into a collaborative group that accomplished many objectives and laid the foundation for future success.

Many of our efforts in 2019 focused on Bryan Health Connect ACO

(Accountable Care Organization) and engaging the six member entities in the process toward clinical integration, population health and success in value-based health care delivery. The ACO member entities include Beatrice Community Hospital & Health Center, Bryan Medical Center, Bryan Physician Network, Crete Area Medical Center, Merrick Medical Center and Saunders Medical Center.

Looking forward, goals for the ACO include:• Promoting local, site-specific process improvement

projects focused on workflows to achieve accuracy in Medicare Annual Wellness Visit, Medical Risk Adjustment scoring, care gap closures and in-network delivery of care.

• Meeting the required metrics and cost savings for the Blue Cross Blue Shield of Nebraska value-based contract and the Medicare Shared Savings Program (MSSP) to attain shared savings.

• Perfecting data reporting to bring meaningful information to our providers to affect population health improvement.

• Partnering with clinical pharmacists on improvement projects.

• Focusing on care coordination in chronic care management and transitional care management.

Stephen Russell, MD Chief Medical Officer

This was a significant year of growth for Bryan Health Connect and the ACO. Some noteworthy successes include:• Growing the PHO membership by 11%. • Entering the Medicare Shared Savings Program with CMS for our first arrangement that included downside risk. • Creating the first mission and vision statement for BHC.

Bryan Health Connect will continue to refine its strategic goals and tactics to ensure membership value and continued forward growth.

The addition of Dr. Stephen Russell as our chief medical officer has been a key enhancement to the team. We applied to participate in the Program 1817 grant, whose purpose is to develop innovative state and local public health strategies to prevent and manage diabetes, heart disease and stroke.

Development of our ACO Operations Council has helped us to more narrowly focus efforts to be successful in all of the contracts under the ACO. We successfully prepared for and attested to CMS with our clinical quality scores for 2019.

Patrick Ganyo, CMPE President & Executive Director

MissionWe connect a network of

resources, innovative leadership and data to drive cost-effective

population health improvement.

VisionLeading exceptional

health care transformation.

Page 1 | Bryan Health Connect 2019 Annual Report

Year in Review

677 physicians

727 non-physicians

262 Non-Lincoln

physicians415

Lincolnphysicians

24 Critical Access

Hospitals1 non-CAH

Bryan Health Connect membershipcomprises:

1,404 Provider Members (as of 12/31/19) 677 Physician Members415 Lincoln Physicians262 Non-Lincoln Physicians

727 Non-Physician Provider Members

25 Hospital Members24 Critical Access Hospitals1 Non-Critical Access Hospital

9 Facility Members4 Ambulatory Surgery Centers1 Imaging Center 2 Dialysis Centers 1 Digestive Health Center 1 Endoscopy Center

4 Ambulatory

Surgery Centers

2 Dialysis Centers

1 Imaging Center

1 Endoscopy Center

1 Digestive

Health Center

Bryan Health Connect is a physician-led Physician Hospital Organization (PHO) created to represent physician practices, facilities, hospitals and other providers. It’s goal is to offer a clinically and financially-integrated, high-quality, cost-effective network of providers to insurers and patients. Bryan Health Connect currently represents more than 1,400 providers.

We work closely with our members, helping them maintain independence in an ever-changing health care environment, and supporting them with services that add value to their membership.

BHC is governed by a 15-member board of trustees from three classes of members:

• Lincoln independent physicians (5)• Heartland Health Alliance (HHA) Critical Access Hospitals (5)• Bryan Health (5)

MissionWe connect a network of resources, innovative leadership and data to drive cost-effective population health improvement.

VisionLeading exceptional health care transformation.

StaffRyan Brunken, BBS Payer Relations & Support Services Specialist

Patrick Ganyo, CMPE President & Executive Director

Wanda Kelley, MSN, RN-BC, PCMH-CCEClinical Integration & Population Health Manager

Kim Larson, BBS Member Services Coordinator

Sharon Leners, BSNGrant & Clinical Linkage Coordinator

Stephen Russell, MD Chief Medical Officer


About Us

11% increase in membership

1,267 members

1,404 members

The Bryan Health Connect (BHC) membership’s primary care providers and specialists serve patients across Nebraska and into Iowa, Kansas, Missouri and South Dakota. BHC membership grew substantially in 2019. We began the year with 1,267 members and ended with 1,404. BHC staff actively meets with potential members to discuss the benefits and value of membership.

Provider CategorizationThe table graph below displays a rough breakdown of the different types of providers that comprise the BHC membership.

DNP/APRN 229CNM/APRN 6CRNA 111DDS 1AuD 3DO 61OD 2SLP 4OT 10DPM 9DPT/PT 32PA/PA-C 206LDAC, LMH 110LMNT/RD 3MD 617

1404

DNP/APRN - 227MD - 621

PA/PA-C - 206

DO - 61

LADC, LMHP, LIMHP, PhD, PsyD etc - 110

CRNA - 111

DPT/PT - 32

OT10

DPM9

SLP- 4

DDS1

OD - 2

LMNT/RD - 3

AuD3

About Our Members


2020 BHC Board of Directors Jeffry Ailes, MDAdvanced Medical Imaging - Lincoln

Troy Bruntz, CEO Community Hospital - McCook

Nicole Ericksen, MDInpatient Physician Associates, LLC - Lincoln

Patrick GanyoBryan Health Connect - Lincoln

Nancy Glaubke, CEOValley County Health System - Ord

Russ Gronewold, President and CEOBryan Health - Lincoln

William Johnson, MDNebraska Pulmonary Specialties, LLC - Lincoln

Jared Kramer, MDHoward County Medical Center - St. Paul

Lynette Kramer, MD (Chairperson) Boone County Health Center - Albion

Gustavo Machado, MD Prairie Orthopaedic & Plastic Surgery - Lincoln

Clyde Meckel, MDBryan Heart - Lincoln

Eric Mooss, CEOBryan Physician Network - Lincoln

Roger Reamer, CEO (Secretary/Treasurer) Memorial Health Care Systems - Seward

Stephen Russell, MD (Vice Chairperson) Complete Children’s Health - Lincoln

Leslie Spry, MD Lincoln Nephrology & Hypertension - Lincoln

Suzanne Vandenhul, MD Southeast Lincoln Family Medicine & Internal Medicine - Lincoln

Regina Burgh, ControllerBryan Health - Lincoln

Mike Dewerff, CFOBryan Health - Lincoln

Patrick Ganyo Bryan Health Connect - Lincoln

James Griesen, PhD (Medicare Beneficiary)Lincoln

Rick Haraldson, CEOBeatrice Community Hospital & Health Center - Beatrice

Sharon Harms, Interim CEOMerrick Medical Center - Central City

Jessica Heckman, MD (Secretary/Treasurer)Family Medicine of Lincoln - Lincoln

Steph Hollman, Interim CEOCrete Area Medical Center - Crete

Hank Newburn, MDSaunders Medical Center - Wahoo

Steve Paulmeyer, MD (Vice Chairperson) Beatrice Community Hospital & Health Center - Beatrice

Stephen Russell, MD Complete Children’s Health - Lincoln

Suzanne Vandenhul, MD (Chairperson) Southeast Lincoln Family Medicine & Internal Medicine - Lincoln

Alissa Clough, MDInpatient Physician Associates, LLC - Lincoln

Elizabeth Dayt0n, DOBeatrice Community Hospital & Health Center - Beatrice

Erin Dorn, PA-C Beatrice Community Hospital & Health Center - Beatrice

Karsen Duncan, PharmDBryan Health - Lincoln

Russell Ebke, MDCrete Area Medical Center - Crete

Patrick GanyoBryan Health Connect - Lincoln

Clyde Meckel, MDBryan Heart - Lincoln

Stephen Russell, MD (Chairperson)Complete Children’s Health - Lincoln

Leslie Spry, MDLincoln Nephrology & Hypertension - Lincoln

2020 ACO Board of Directors

2020 Clinical Guidelines & Quality Assurance Committee

Governance


Transforming Clinical Practice Initiative (TCPi)Bryan Health Connect participated in a four-year grant that was launched in 2015 by the Centers for Medicare & Medicaid Services (CMS), known as the Transforming Clinical Practice Initiative (TCPi). This grant supports clinician practices through nationwide, peer-based learning networks to help them achieve large-scale, health care transformation, prepare to successfully participate in value-based payment arrangements - including Alternative Payment Models (APMs) and to improve the quality of care.

Primary Goals of TCPi

• Help more than 140,000 primary and specialty care clinicians enrolled in Practice Transformation Networks (PTNs) and Support and Alignment Networks (SANs) to achieve practice transformation and provide education on the implications of the Quality Payment Program (QPP).

• Build an evidence base on practice transformation so that effective solutions can be scaled. To achieve this, TCPi developed, captured and reported a standard set of measures, aligned with the overall goals of Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the QPP. Best practices and lessons learned were shared to support practice transformation and practice transitions into alternative payment models.

• Improve health outcomes, reduce unnecessary hospitalizations and reduce over-utilization of other services for 5 million Medicare, Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries and other patients.

• Sustain efficient care delivery for Medicare, Medicaid and CHIP beneficiaries by preparing at least 75% of practices that complete the TCPi phases of transformation to move into APMs.

IHC Practice Transformation Network (PTN) Bryan Health Connect (BHC) partnered with the Iowa Healthcare Collaborative Practice Transformation Network (PTN) during the four years of the TCPi grant.

In this final year of TCPi participation, 12 BHC ACO participating practices advanced to alternative payment models by demonstrating the skills to participate in value-based payment models. They are dedicated to demonstrating success in achieving outcomes based on continuous, data-driven quality improvement practices and creating sustainable business operations.

Participants include:• Beatrice Internal Medicine• Beatrice Medical Center• Beatrice Women’s & Children’s Clinic• Bryan Heartland Psychiatry• Bryan Neurology• Bryan Urgent Care• Center for Maternal & Fetal Care• Gage County Medical Center• Lincoln Aesthetic Surgical Institute• Saunders Medical Center• Wymore Medical Clinic

Alternative Payment ModelsMoving to alternative payment models was a main focus in the last year of TCPi. Several TCPi participants were engaged in activities to begin transformation to an alternative payment model. These practices participated in webinars, conferences, one-on-one meetings and educational activities to enhance their knowledge in these areas. BHC showcased these partners as being progressive, dedicated to quality improvement and moving toward value-based payment models. These practices include:

• Associated Anesthesiologists• Bryan Heart• Inpatient Physician Associates• Lincoln OB/GYN PC• Nebraska Pulmonary Specialties• Urology PC

Although the four-year initiative has ended, the work will proceed. Many tools and resources became available during these four years. CMS shares these resources with any practice that has an interest in utilizing the strategies that are effective in transforming clinical practices and improving health care delivery and patient outcomes. These resources may be found at: https://innovation.cms.gov/innovation-models/transforming-clinical-practices

We showcase the following exemplar practice stories provided by two BHC TCPi participating practices.

The Compass Practice Transformation Network is supported by Funding Opportunity Number CMS-1L1-15-003 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the views of the U.S. Department of Health and Human Services or any of its agencies.

Grants

Clinical Support


Exemplar Practice Story: Saunders Medical Center - Wahoo, NE

Patient-Centered Goal

Saunders Medical Center (SMC) created an aim statement to reduce 30-day readmissions by 50% by December 2018 and sustain a readmission rate of less than 4%. We initiated interventions (see right) to help reachthe goal of reducing 30-day readmissions and improving patient outcomes.

Results Reflecting on these interventions, as well as considering patient satisfaction surveys in previous years, SMC has made great strides. Reducing the all-cause 30-day readmission rate to below 2% in 2018 exceeded our overall goal. The entire staff at SMC pushed toward this goal and promoted a health-focused lifestyle. As we work with the community, we are creating a strong foundation for healthy living in our rural areas.

Both SMC and our patients have seen financial gains amid our interventions. By decreasing our readmission rate, we are promoting our high quality care by getting things right the first time. This prevents patients from coming back for high-cost health care such as re-hospitalizations or emergency care. The Transitional Care Management Services (TCMS) also have added a financial gain that we have not utilized in the past. In the previous two years, SMC had more than $35,000 of revenue by using TCMS. By reducing the readmission rate, according to the Health Research & Educational Trust Hospital Improvement Innovation Network (HRET HIIN) calculator, eight harms were prevented in 2018 alone and more than $118,000 of costs were avoided.

Lessons Learned

During this improvement phase, we have learned several lessons:

• We have had many gains in this process that involve inspiring healthy lives to take root at SMC by strengthening our model of care to promote and support active and health-focused lifestyles.

• We have created and sustained community relationships and are utilizing our community resources with the help of our social worker.

• Areas we have identified for improvement include expanding and teaching our staff how to appropriately use the Tell Me 3 and teach-back method on every patient.

• We would like to expand the hospital health coach role into being a true discharge planner. With these new goals in mind, we are confident that SMC will provide the best patient experience possible, improve patient outcomes, reduce costs and prevent readmissions.

Harm Measure Monthly Baseline

Numerator

Monthly Baseline

Discharges

Baseline Rate per

1,000

Target Rate

Project To Date

Numerator

Project To Date

Discharges

Project To Date Rate per

1,000

Harms Prevented

Cost per

Harm

Costs Avoided

Readmission Rate 30-Day All Cause

1 10 54.95 48.35 10 321 31.25 8 $15,477 $118,203

GOAL REACHED!

Care Transitions

Collaborative

Patient Family Advisory Council

Complimentary Home Visits

TransitionalCare Mgmt

Services

Follow-Up Calls

SMC Care Line

Health Coach

Successful Interventions

Start

Clinical Support


Clinical Support


PATIENT DISCHARGE COORDINATION• Healthcare outcomes and recidivism are influenced by

patient and family engagement with plan of care.

• Includes organizing patient’s plan of care in anticipation for hand-off to next level of care.

Actions• NC role modified to enhance patient care

coordination.• Pilot study for selected units to evaluate intervention

effectiveness.

Sustainability Plan• Internal and external coordination of care development;

data review.• Co-management agreements with practice groups.

Lessons Learned• Established culture and priorities vary per hospital unit.• Administrative burdens for facility placement are time

consuming.

Paths we chose...

ACCURATE AND COMPLETE DOCUMENTATIONLevels the playing field for risk-adjusted analysis of patient outcomes:• Mortality• Readmissions• HAC/HAI

Actions• Education on why/how (patient case reviews, poster

presentations, weekly topics, outreach to CDI staff/resources).

• Initial goal: Increase CMI rates 10% above baseline.

Sustainability Plan• Ongoing education refreshers via multiple modalities;

data review.• Regular collaboration with clinical documentation staff.

Lessons Learned• Knowledge base for specificity with documentation

varies widely.• Small steps and reinforcement are most effective to

scale success.

Quality Ratings (Patient outcomes)

Reimbursement (DRGs, CM I, etc.)

Expected Length of Stay ( by early recognition and

management of co-morbidities)

Value-Based Purchasing/P4P (Mortality, Readmissions, HACs)

Documentation Coding =

Pam Shelbourn, MSN, RN; Brenda Sebek, MSN, RN; Alissa Clough, MDAffiliated with Bryan Medical Center - Lincoln, NE

Trek to Transformation: Inpatient Physician Associates - Lincoln, NE

Early Steps on this journey align with TCPi goals...

• Improve health outcomes for patients• Transform processes to prepare for participation in APMs

Bryan Health Connect works diligently to research and secure products and services and provide information, education and events that will provide value to its members. This work has resulted in several new member services that will be offered in 2020. BHC currently offers several options of value for members:

Debt CollectionMerchants Collections Adjusters (MCA) changed their name in spring 2019 to Clear Recovery. They offer an exclusive collection fee rate and a resolution-based approach that is designed specifically to health care.

Medical Malpractice & Liability InsuranceCOPIC offers BHC members exclusive benefits of reduced premiums, educational opportunities, a 24/7 physician-staff hotline and more.

Group PurchasingProvista offers BHC members discounts on group purchasing. With their extensive network of suppliers, BHC members have many choices for their business needs.

Bryan Health Connect began holding monthly update calls with each member services partner to enhance collaboration and communication and strengthen rapport.

Payer CredentialingBHC performed credentialing services for 366 providers in 2019. This service includes adding providers to a choice of several commercial and government payers, and working with those payers to resolve any issues that a provider could potentially encounter.

We work closely with the BHC Credentialing Committee to ensure that providers meet the high standards of ethics and high quality care.

As the Bryan Health Connect (BHC) Credentialing Committee Chair, I am responsible for overseeing the payer credentialing process and reviewing the applications.

The credentialing process requires that health care providers be truthful and open about their training, licensure and scope of practice. BHC wants to foster a network of providers that will allow us to negotiate with payers in the health care insurance market. I am a part of Bryan Health Connect in order to be surrounded by high quality providers.

Leslie Spry, MD Lincoln Nephrology & Hypertension

Member Services


Managed Care ContractsBHC members have access to “Messenger Model” payer contracts for BHC members only:

• Blue Cross Blue Shield of Nebraska (BCBSNE) Network Blue & Select Blue product offering• WellCare of Nebraska (Managed Medicaid) offering• Nebraska Total Care (Managed Medicaid and Pay for Performance) offering• Midlands Choice offering• UnitedHealthcare (Commercial, Medicare Advantage and Managed Medicaid)

In 2019, BHC messaged out a UnitedHealthcare managed care contract.

Tier 1 Domestic Provider StatusIn addition to opt into BHC’s managed care payer contracts, member providers have an exclusive option to become a Tier 1 domestic provider for employees and their dependents who are enrolled in the Bryan Health employee health plan. This plan includes more than 8,500 covered lives.

Communications & MarketingConnections e-newsletterThis bi-monthly electronic newsletter is available to all members of BHC, containing current topics of interest, updates, information, events, education and member news.

Managed Care Messenger e-newsletterThis monthly electronic newsletter is geared toward providers, practice managers and financial managers who are monitoring payer relations. It summarizes recent updates and the current status of policies and procedures from managed care payer organizations.

WebsiteThe Bryan Health Connect website maintains an up-to-date listing of in-network providers that enables searching by specialty, name, practice name and location at bryanhealth.org/bryan-health-connect/provider-members. Also available on the BHC website is a listing of member services and events. Look for new features and information on the website this year (2020).

Member Services


Education & EventsMember ForumsBryan Health Connect hosted quarterly member forums in 2019. Along with education, each member forum began with an update of the status of the PHO by the president & executive director; the member services coordinator also provided a member benefits update. February 21, 2019MIPS - What’s New for 2019?Presenter: Wanda Kelley, MSN, RN-BC, PCMH-CCE, Clinical Integration & Population Health Manager - Bryan Health Connect

May 13, 2019The Opioid Epidemic: A Public Health Crisis Presenter: Brenda Mueller, MS, LMHP, LADC - Bryan Independence Center

Pain Management and Opioid Stewardship Program (PMOSP) Presenter: Celia Weskamp, PharmD - Bryan Health PMOSP Program Facilitator

August 21, 2019 Understanding Physician Compensation Models for Sustained Success in a Value-Based Care World Presenter: Tara Wisdom, CFO - OrthoNebraska (former Healthcare Consulting Director at Lutz)

November 13, 2019Quality Payment Program: How Is It Going for You?Presenter: Wanda Kelley, MSN, RN-BC, PCMH-CCE, Clinical Integration & Population Health Manager - Bryan Health Connect

Bryan Health Connect ACO, LLC Annual MeetingBryan Health Connect ACO, LLC, hosted its first annual meeting on Nov. 9, 2019. Eighty-one percent of ACO provider members attended in person or virtually.

Keynote speakers included Dr. Mike Romano of Nebraska Health Network, speaking on value-based contracts, clinical integration, population health, Medicare Shared Savings Program, Medical Risk Adjustment, Medicare Annual Wellness Visits and quality metrics; and Patty Gould, DNP, MSN, RN, CPHRM, Senior Manager, Midwest Patient Safety/Risk Management at COPIC, presented on the top five challenges facing health care.

TCPi participants also were available to present their projects to attendees.

CMEs were provided for: • Completion of education modules

- Value-based Care & Clinical Integration - Medicare Annual Wellness Visit - Medical Risk Adjustment

• Attendance at ACO Annual Meeting

Member Services


An Accountable Care Organization (ACO) is an organization of health care providers that has these purposes: 1) To function as an accountable care organization and promote high-quality, cost-effective medical care by arranging medical services for members of the community; and 2) To achieve CMS’ three-part aim of better care for individuals, better health for populations and lower growth in expenditures.

Bryan Health Connect ACO, LLC, is an Accountable Care Organization established in 2017. It is made up of Bryan Health Connect member physicians, hospitals and other health care providers who work together for quality of care, patient health care needs, patient experiences and reduced costs. Much of this work is delivered through population health management activities involving the ACO participants.

The ACO participants are primary care providers dedicated to increasing the value of care for the patients we serve. To support this work, ACO stakeholders must contribute to both quality improvement and cost and utilization reduction.

In 2019, the ACO was focused on steering the six member entities toward clinical integration, population health and success in value-based health care delivery. The six ACO member entities:

• Beatrice Community Hospital & Health Center• Bryan Medical Center• Bryan Physician Network• Crete Area Medical Center• Merrick Medical Center• Saunders Medical Center

Annual Wellness Visits, Medical Risk Adjustment & Hierarchical Condition CodingAn early focus was on value-based care concepts, Medicare Annual Wellness Visits (AWV) and accuracy in attributed population medical risk adjustment scoring (MRA). All ACO entities received on-site education regarding the new paradigm of value-based care, AWVs and Hierarchical Condition Coding (HCC). We also developed web-based AWV and HCC education modules to expand education access throughout the network.

Medicare Shared Savings Program (MSSP) A scorecard was created and implemented for the Medicare Shared Savings Program contract based on 10 quality metrics in the following areas:

• Preventative Health• At-Risk Population • Care Coordination• Required Threshold

This scorecard is used to qualify member entities for shared savings distributions. Scorecard education was completed by the BHC team to support medical directors with respective provider member education. All six entities met the required annual threshold measures by Dec. 31, 2019.

We will continue to focus on local, site-specific process improvement projects to improve workflows and achieve accuracy in AWV, MRA scoring, care gap closures and in-network delivery of care.

BCBSNE Value-Based Contract

Data & AnalyticsAn imperative for success is accurate, efficient and meaningful data collection and reporting as it affects quality metric tracking, gaps in care, in-network/out-of-network care (leakage), high spend areas and provider feedback. Koan Health, a health care insight platform supported by our relationship with Nebraska Health Network (NHN,) is our springboard to creating the products to meet this need. Collaboration with the Bryan Health data analytics team is ongoing with the goal to eventually sustain data analytics internally.

ACO Operations CouncilAn operations council was created and convened its first meeting in late 2019. The council includes the six ACO members’ CEOs, CMOs, quality leads and practice managers that are led by the BHC team. This council will be the forum going forward for collaboration, best practice sharing, change management, updates, team building, clinical improvement and cost reduction.

Population Health InitiativesThe ACO participants are primary care providers dedicated to increasing the value of care delivered to the patients we serve. To support this work, ACO stakeholders must contribute to quality improvement, cost reduction and appropriate utilization.

74 providers

6 Entities

13,394 attributed lives

Year one of Bryan Health Connect ACO’s value-based contract with Blue Cross Blue Shield of Nebraska (BCBSNE) has concluded. Throughout the year, 10 metrics were tracked with quarterly scoring to reflect gap closure efforts.

In the BCBSNE program, each metric could earn 0, 1, or 2 points for a total of 20 points. At least 10 points are required on the end of year scorecard to be eligible for shared savings.

Accountable Care Organization


ACO staff members set goals for quality and cost that are meaningful and reasonable, and support better care and more positive clinical outcomes for patients. As a newer ACO, our goals included performing a current state assessment of our ACO participants, establishing coordinated and consistent clinical management, developing an information technology infrastructure for ACO data collection and analysis, and implementing quality and utilization management systems for the ACO and its participants.

Below are a few of the 2019 Bryan Health Connect ACO goals and accomplishments:

Current State AssessmentAn environmental scan was performed to determine the ACO participants’ baseline readiness for population health management strategies. This was accomplished using a Patient-Centered Medical Home (PCMH) readiness tool. Each ACO participating entity completed the PCMH assessment survey.

Bryan Health Connect ACO participants’ average scores reflect that the basic elements for each component have been implemented, although the practice still has significant opportunities to make progress within one or more important aspects of a given component. The results of these assessments were analyzed and shared with ACO participants’ leadership teams along with discussion of ACO strategies, value-based care and steps forward.

Clinical Collaboration OpportunitiesArticles to support the ACO clinical initiatives were published in the Bryan Health Connect Connections e-newsletter. Contributions included articles on BHC Population Health Management, Medical Risk Adjustment, Medicare Annual Wellness Visits and Reflections on Accountability.

Annual Wellness VisitsThe operational and clinical processes for Medicare Annual Wellness Visits were reviewed and refined as a means to position our ACO practices to deliver high quality value-based care. An Annual Wellness Visit toolkit was developed and distributed to our ACO practices. The toolkit includes team-based care materials, sample workflows, scripting, assessment, prevention plan, health risk assessment form and patient education materials. Each ACO practice was given Annual Wellness Visit educational sessions and materials. 100% of our providers participated in this education.

ACO Annual MeetingThe first Bryan Health Connect ACO Annual Meeting was held on Nov. 9, 2019. Target audience was ACO participant CEOs, CMOs, quality directors, practice administrators, providers and other staff. We conducted a 4-hour meeting that included speakers and networking, and offered CMEs. The event was well received with 81% of our providers in either live or virtual attendance.

Medical Risk Adjustment Clinical documentation that accurately reflects the complexity of a patient’s condition is vital to delivering value-based care as well as qualifying patients for enhanced disease-related services and access to care management programs. Patient acuity, as expressed in ICD-10 diagnosis coding, also is used by Medicare and private insurers for medical risk adjustment and to set cost goals for providers participating in value-based agreements.

Each ACO practice was provided medical risk adjustment educational sessions and materials. 100% of our providers participated in this education.

Quality Measures Review with IT InfrastructureIn 2019, the ACO implemented a data aggregation tool called Koan Health. This sophisticated data analysis tool provides the ACO data analysis capability that will integrate both claims and clinical data.

Currently, Koan Health draws on two claims data sources to identify new opportunities to improve health outcomes and decrease cost across the ACO. Our goal is to produce and deliver actionable analysis to support improvements in health care, health system performance and population health across the continuum of care.

Components of the survey include:

• Engaged leadership• Quality improvement strategy• Empanelment• Continuous and team-based healing relationships• Organized, evidence-based care • Patient-centered interactions• Enhanced access• Care coordination

Accountable Care Organization


Bryan Health Connect expresses its appreciation to the PHO and ACO board of directors, committee

members, member providers, practice managers, payer representatives, member service partners

and all others who support us in our mission.

We look forward to continuing our support of members as we work together to control

costs and deliver high-quality health care.

Thank you


Bryan Health Connect2300 S. 16th St., Tower A - Suite 210Lincoln, NE 68502402-483-8891

bryanhealth.org/connect

Documents

2019 Annual Report · 2020. 6. 24. · Member Services ... Mike Dewerff, CFO Bryan Health - Lincoln Patrick Ganyo Bryan Health Connect - Lincoln James Griesen, PhD (Medicare Beneficiary)