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“The need to provide better healthcare with lower cost has never been greater, but the journey to value-based care is long and requires organizations to think very differently about every aspect of care. To transform outcomes and improve quality of care across New Jersey, we are creating a virtually integrated network. By combining the expertise of a health plan and a provider, and leveraging real-time patient data, we will ensure the reliable delivery of measurable better care,” explains Thomas Graf, MD, VP, Chief Medical Officer, Horizon BCBS of New Jersey.

Graf is a keynote speaker at the marcus evans ACO & Payer Leadership Summit Spring 2018.

What advice do you have for organizations transforming to value-based care?

The journey is long and it is easy to get lost in the details. The best advice I have for folks is to think carefully about their population, understand the people and communities they serve to design services based on their medical needs. Processes should be developed to push those services out to them or to help them become as healthy as they can be. This will keep them focused on what is important as they go through the turbulence of this transformation.

How can they reduce the cost of care while improving outcomes? What has the biggest impact on that?

The philosophy of focusing on driving quality and letting improvements reduce the total cost of care, rather than just going after the spend. It makes sense to look at certain target areas, including readmissions. If they look at where cost or quality varies the most in their practice area, they will ultimately find that the underlying processes of care also vary dramatically. Looking at variation where there is no connection to quality improvement is an area where they can get the most engagement by the clinical teams. By reducing the variation they can almost always improve quality, which will almost always reduce cost.

Why and how can they build a virtually integrated delivery network? 

There is evidence that the traditionally integrated networks are the most successful in the industry. But for new organizations, it is hard to get there. We believe it is faster and possibly better to take a high performing hospital system, physician group and health plan, and to virtually integrate them. Bring their systems and operations together, culturally integrate them so they think and work as a single team. They must find a partner with the same mindset, both looking to drive quality, reduce cost and drive better outcomes for the community. Then they need to think carefully about where those connection points will be, who will be the interface for each organization, how they will meet, the structure of integration.

We are creating a private network health exchange that allows us, in real time, to push data claims, risk scores and other elements into the electronic environment of the clinical enterprise. At the same time, the enterprise can share with us detailed patient and operations data so we can really operate as a single unit. We are financially separate companies that function as one unit. Many patients think this already occurs, it is time to make it real.

What issues do they usually encounter when integrating networks?

Historically there is a great deal of mistrust between health plans and systems, so the first step is to overcome that. Secondly, making sure there is a strong vision that both sides truly and completely buy into and actively work for. They need to set up those regular and meaningful connection points, build the infrastructure where the work can occur, publicize findings and small improvements and celebrate them, while making sure the big picture of higher quality lower costs remains the goal. We need to understand the challenges of two new organizations working together, build small areas of success and expand them. People must be held accountable and responsible on both sides so the chance of success is greater.

What tools or technologies could they make better use of?

Health plans and systems are often looking at patients with half of the map missing. It is difficult to figure out where to go when you cannot see the full picture. They need access to data of what also happens outside their walls. That information should be available at a very granular level and as close to real time as possible.

The other advantage of a virtually integrated network is that it can shape the terrain of the way patients get their care by changing benefit design. We want to encourage patients to go straight home after hospitalization but benefits should be set up to facilitate that.