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With the health details of more than 50,000 people loaded into a nimble analytical framework, the Granite Healthcare Network is well on its way to providing its five member health systems a plan for controlling costs while doing better for their target population. But success lies in the structure of the network and its ability to reap what it sows in that analysis.

"Some people have the analytics, and it's great to have the data, but it's what you do with it that really matters," says Rachel Rowe, the New Hampshire network's executive director. An infrastructure to coordinate care, disseminate best practices learned from analysis and follow through on recommended changes is what has made a difference. "We're getting very sophisticated in using business analytics to manage populations at risk," she says.

Granite Healthcare Network's first targets, isolated through claims analysis, are asthma, emergency department admissions and the use of high-end imaging for low back pain, and that's all in a shared-savings agreement with Cigna. "We have a collaborative, accountable care contract as a whole, and we're at risk as a group of five systems." Rather than negotiating rates, the systems share a medical cost target, with a quality-metrics component, and if they collectively get below that, all will share the savings.

The geographic coverage and combined effort to control expense while improving clinical results are what payers are looking for, says Steve Gelineau, a consultant with the Camden Group. "As these collaborations mature, they're able to develop, for example, shared standards of care, shared care models, shared care protocols and shared quality standards that are utilized back to the disparate hospitals that make up this collaborative network. Now this network can go to the payers and say, 'We have a uniform delivery system here,' " he says.

An efficient, quality-producing network could be a plus for payers in their efforts to fully serve their members and attract new members, while bending their cost curve and sustaining it, says James Smith, senior vice president of the Camden Group. "You've brought together a scalable entity, and an enterprise that you're governing and making investments in, that are at least providing services under one umbrella with common benchmarks [by which] you can show value to the payer and to the member," Smith says.

Every quarter, all Granite providers get a fresh set of metrics from analytics vendor Verisk Health on how they're doing. The analytical tools allow pinpointing at the practice level, down to the ordering physician, says Rowe. All chief medical officers from the five systems meet "every two weeks for two hours face to face, using that information to say, 'Gee, how come you, Southern New Hampshire [Health System], have fewer gaps for asthma patients than we do? What are you doing differently, what are your strategies, how do you incent your providers, how do you put processes in place?' "

Ultimately, there has to be a strategic imperative to decrease costs together, she says. "It's great to have the analytics, and it's great to have the care coordinators working with the patient, but you also have to change physician behavior. You have to have physicians not ordering the MRI when a patient has only had low back pain for two weeks rather than six weeks. So there's a whole evidence-based practice piece." And incentives include accountability to Cigna for improved care, as well as Medicare, she adds.

Remembering the Big Picture

Collaborative networks can have other goals short of payer contracts. "We're not even thinking about assumption of risk," says Denise Young, the coordinator of North Country Initiative, with seven rural hospitals in far upstate New York. "We have a strong case for our ability to reduce cost, but not assumption of risk. Not yet."

The initiative has all it can do just getting the complement of hospitals to see the big picture of the new health delivery model as it materializes, says Young. It's a chance for hospitals and physicians "to talk about and work on things that have to happen related to reducing cost of care, improving quality of care and impacting our population health."

Young heads a local nonprofit, the Fort Drum Regional Health Planning Organization, which seeks to examine how the region's health care system can be strengthened in ways that health care leaders find difficult to contemplate on their own. "Each of these hospitals, and their physician practices as well, is so head-down in delivering service," she says. "Small places just don't have the capacity to have people whose jobs it is to keep their heads up, looking at the horizon and [saying], 'Wait, wait, wait, we need to be prepared for this or we need to be prepared for that.' "

The planning organization already has launched programs to strengthen work force, emergency services and other types of collectively beneficial services in its six-year existence. Overall, improvement in health information technology, including use of telemedicine, "has been on our radar for a while," says Young, explaining that area health systems have to structure their information-sharing for the changes that are coming. "The reality is, we have to have standardization in order to have good data, and we have to have good data in order to react in a way that's going to lower our cost and allow us to keep our population health," she notes.

Human Contributions

As important as infrastructure is the human component of a combined improvement effort, says Gelineau. Both the Granite Healthcare Network and North Country Initiative have "very high levels of engagement across substantial categories of individuals," he says. Camden Group has consulting arrangements with both collaboratives.

The sharing of superior practices going on in different areas of each member system is a big part of what made the BJC Collaborative attractive, says Sandra Van Trease, a group president of BJC HealthCare, St. Louis, one of the collaborative's founding members. "We had this opportunity to get very smart people together on a regular, organized basis to learn from each other about how to take what's been happening at one shop and be able to transfer that — that knowledge transfer — to another without a whole lot of startup cost."

That includes demonstrating some early successes. "Unlike a merger, where you are legally bound to each other, this is a collaborative, these organizations are coming together voluntarily to work on specific areas," says Van Trease. "And people are very busy — so you have to prove that this is worth senior executive and board time."

For more on IT-driven collaborations among independent hospitals, please read our February cover story, "Strategic IT Alliances."

John Morrissey is a freelance writer in Mount Prospect, Ill.