Delivery of Care

Investing in the future of accountable care at Care New England

An exclusive interview with president and CEO Dennis Keefe, and his interim successor, Dr. James Fanale

Photo by Richard Asinof

Dr. James Fanale, left, and Dennis Keefe. Fanale will succeed Keefe as interim president and CEO on Jan. 1, 2018, following Keefe's retirement.

By Richard Asinof
Posted 10/2/17
The leadership at Care New England talked about the successes it has achieved in developing its Integra Accountable Organization, improving care and reducing costs, in an exclusive interview with ConvergenceRI.
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PROVIDENCE – We have not had a lot of great news coming out of Care New England lately, Dr. James Fanale told ConvergenceRI in a recent interview, but indicated that may be about to change.

Fanale, who currently serves as the health system’s chief clinical officer and chief operating office, will begin serving as the interim president and CEO on Jan. 1, 2018, following the retirement of the current president and CEO, Dennis Keefe.

Some information he could share, Fanale said, were that the cost savings for some 14,000 Medicare Advantage Blue Cross members in 2016: Integra saved $3 million in the cost of care for that population, with Integra receiving $1.6 million of that amount, which was distributed in part to the primary care providers who helped to manage the program.

Breaking away from fee for service

The Integra Accountable Care Organization was created in 2014, and since then, has grown to include more than 130,000 members. Unlike other ACOs, which are employer-based models, Integra is a blend of hospital-based physicians and nurses working together in partnership with private community physicians and nurses who are members of an independent practice association, explained Dr. Al Puerini, who is the chair of the board of Integra.

“We meet together on a monthly basis, we discuss cases, we figure out how to do things better,” Puerini said, describing what he believes is at the core of the success behind Integra.

The evolution has been pretty cool, he continued. “We now have specialty groups in dermatology, orthopedics and gastroenterology, we work with them on a regular basis, streamlining the referral process, creating a better patient experience, and streamlining communications among the specialists and the primary care providers.”

One of the tools that have helped Integra improve communication and collaboration has been a dashboard created by the Rhode Island Quality Institute that literally tells the ACO network where patients are in real time, Puerini said.

“I’ve been involved in health care for 40 years, and there has never been this much collaboration. We actually meet face-to-face with specialists to talk about protocols and patient satisfaction. We’re following the patients from soup to nuts.”

Participants in the Integra ACO include the R.I. Primary Care Physicians Corporation and South County Health. The focus is on providing a continuum of care to improve population health. In January of this year, Integra was chosen by CMS to become one of 20 Accountable Health Communities in the nation, focused on addressing the social determinants of health.

In just two years, the efforts under Integra have resulted in the decline of utilization of hospital services at Kent Hospital, including admissions and readmission, which Fanale said was a quality indicator of better care. [On the financial side, by investing resources in population health, improving care and producing cost savings for the system, the decline in patient volume can also contribute, in the short term, to a decline in revenues, as the business model for hospitals transitions from fee-for-service to population health and bundled reimbursements for a continuum of care.]

“We are always trying to make sure that patients who need to be admitted, get admitted, but only when they need to,” Fanale explained. “That care gets managed in the right place at the right time, [that patients are admitted] not any longer than they need to be.” As a result, admissions are down at the hospital, length of stay is down, skilled nursing facility utilization is down, and the quality scores are better.”

Here is the ConvergenceRI interview with Dr. James Fanale and Dennis Keefe, as the baton of leadership at Care New England is passed, and the presence of the Integra Accountable Care Organization continues to grow, currently serving more than one out of 10 Rhode Islanders.

ConvergenceRI: What are the results of the Integra Accountable Care Organization that you can talk about?
We can directly correlate the decline in volume at Kent with the decline in utilization of hospital services by our population. Quite frankly, we have put a lot of resources in taking care of the population that would result in these declines.

KEEFE: It’s admissions and readmissions.

FANALE: Yes, admissions and readmissions are down.

KEEFE: Readmissions are down, which is really, arguably, a quality indicator. Admission days are down. Hospitals are dangerous places, you know.

FANALE: They are great places when you need to be there, but not great places when you don’t need to be there.

KEEFE: Right. So the fact is that the admissions are down. But when [patients] are admitted, they spend fewer days in the hospital.

[These results] were not magical stuff that just happened. Length of stay since my arrival has been pretty flat, pretty stable; if anything, it has been slightly up. We have reduced length of stay by an average of one day in a year, which is extraordinary in the hospital business.

FANALE: [With Integra], we built this complex care management team to take care of our sickest of folks; we have resources in the community, we have care management resources in the ED. We are always trying to make sure that patients who need to be admitted, get admitted, but only when they need to; that they get managed in the right place at the right time and not any longer than they need to be.

So, admissions are down at the hospital, length of stay is down, skilled nursing facility utilization is down, and the quality scores are better.

For the first time, we have dropped readmissions at Kent in the Medicare population significantly because of this work.

On the financial side, one thing we do know: in 2016, for the 14,000 Medicare Advantage Blue Cross members, we saved $3 million in cost of care for that population, of which Integra received $1.6 million. And, that gets distributed to [cover] the costs of the system as well as the primary care providers who help to manage it.

It’s very important to make sure we emphasize our partnership with our physicians.

ConvergenceRI: Let me step back a bit here. You’re retiring, you’re passing the leadership baton, if that’s the right phrase,
On a good day, it’s passing the baton.

One of the things that is very interesting, in a world where there are still not many ACOs, both Jim and I personally had prior experience in developing accountable care organizations.

I did it before I came here, at the Cambridge Health Alliance, and Jim did it at Jordan Hospital in Massachusetts; it was one of the pioneer ACOs. It’s unique.

Both Jim and I have specific, long-standing experience with ACOs and population health.

In terms of passing the baton, I’m not a physician, but I know how to [build the architecture of] an ACO, and how to get the right pieces in place, and how to really create success going forward.

So, by recruiting Jim, who is a physician and has all of this clinical experience, it’s a perfect situation, from my perspective, in terms of the vision of what we’ve been trying to achieve, and leaving in good hands, in someone I believe to be one of the national experts when it comes to population health.

FANALE: Let’s not get too schmaltzy. We haven’t had a lot of great news coming out of Care New England lately. But [the results we have achieved with Integra] is a really positive story. We have 130,000 members; the state asked to do Medicaid [and we did it]; we’ve done Medicare, we’re doing commercial. We’re the largest ACO in Rhode Island. We took on risk this year; the other ACOs don’t take on risk.

We are a hospital-based ACO. Coastal Medical does a great job [with its ACO], but it’s a different model.

KEEFE: It’s an employer model; we have an independent practice association model.

FANALE: Here’s another piece that is incredibly important: we received [a grant to create] an Accountable Healthy Communities, one of the 20 in the country. Integra is not only paying attention to health care and complex care needs, we now will be spending five years working on the social determinants of health, which is the key to success [in population health].

I don’t think you are going to find a more well-rounded, dedicated ACO in the country in the country that has all this stuff.

When we began Integra, we didn’t have a staff member until two years ago. We have achieved an overwhelming positive performance in both quality and cost in the Medicare population for 2016. It’s incredible.

And, in 2017, we’re tracking positive results for Medicare and commercial [insurance plans].

Finally, on the Medicaid side, working very closely with the seriously mentally ill folks, we have been able to demonstrate that we can improve their care and cost of care as well.

I think that if we are the not the trailblazers, then nobody else is.

ConvergenceRI: How do you define population health?
It’s caring for the population in the highest quality manner while improving the cost of care. It’s a value equation.

KEEFE: It’s a value proposition. Quality is still at the center of the vision, but it is about providing that quality in a way that actually reduces the cost of health care.

FANALE: Who thinks that when you have a very sick patient, one that gets admitted to the hospital 10 times year, that that is good?

The best way to reduce the rate of readmission is not to admit them. That’s kind of a facetious statement, but when you think about it, we work very hard to make sure that when a patient gets admitted, they get the right stuff they need, and then we try to get them back home as soon as we can.

We have a great VNA, we have a great hospice; we probably have the most developed hospital-based palliative care program. The palliative care approach we have here is more robust than anyplace I’ve been.

ConvergenceRI: Shifting gears, how does work translate with Partners? Does Partners appear to appreciate the value of this work moving forward? I don’t know what you can say about this.
We have had ongoing conversations with them about population health, about how we can cooperate and collaborate. They see themselves as a national leader in the area of population health. They have more of an employer model; we have an IPA.

ConvergenceRI: Is everything proceeding well with the sale of Memorial? Once again, I don’t know what you can say.
Yes. I need to choose my words carefully. The goal here is to get as quickly as possible what’s called a signed purchase asset agreement, and we are in active negotiations. We’re hopeful that it will come to completion in the very near future. But I can’t define the very near future is.


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