This article originally appeared in Healthcare Informatics and was authored by Mark Hagland, Editor-in-Chief at Healthcare Informatics.

Can a physician organization that serves an underprivileged population make it in a managed care-driven environment? The folks at Yakima Valley prove it can be done.

About 150 miles away from the glamour and hip chic of Seattle, the Yakima Valley lies in the heart of Washington state’s agricultural and viticultural heartland, with apple, peach, and cherry orchards, bell pepper and corn fields, and vineyards, stretching as far as the eye can see. It is a very blue-collar region, and the Yakima Valley community includes many migrant workers, some of them undocumented, and many uninsured or underinsured.

Caring for about 130,000 area residents annually, the Yakima Valley Farm Workers Clinic (YVFWC) embraces its community, while its senior executives, led by CEO Carlos Olivares, have been working furiously to optimally serve their community in ways that acknowledge the perpetually straitened healthcare budgets involved. Indeed, they recognize that there will never be an abundance of resources available to serve the Yakima Valley patient population, 90 percent of whom fall below the poverty level.

That’s why Olivares and his colleagues at the Toppenish-based YVFWC, which encompasses 26 outpatient care sites, 1,400 staff, and 95 physicians and allied health professionals (52 physicians and 43 nurse practitioners and physician assistants; in addition, about 100 behavioral therapists are on staff), have had to create invention out of necessity, in order to optimally care for their hardworking, underprivileged population.

The key to enabling Olivares and his colleagues to optimally serve this community, after 35 years of effort? In a word, data, says Olivares. “Typically,” he says, large organizations look at their future, and begin to analyze data they already have, and then they say, ‘What do we want to do five years from now?’ That level of strategy is much more difficult to successfully pursue in small organizations that don’t have the data systems the larger ones have.” What’s more, he says, “We cannot continue to ask our providers to work harder, see more patients, document more, and improve patient care. We need to tap into our data to help them make the right patient care decisions, faster, and with greater accuracy.”

As a result, Olivares and his colleagues have invested heavily in IT, building a robust data warehouse that encompasses data from more than 10 sources; developed a comprehensive set of clinical reporting tools that integrates directly into the clinical workflow of the organization and provides physicians and other clinicians with dashboard-based indicators for chronic care management; and have outsourced data analytics management to a vendor partner (the Burlington, Mass.-based Arcadia Healthcare Solutions), resulting in the freeing-up of time and intellectual energy on the part of senior YVFWC leaders to focus on IT and data strategy instead of core system maintenance.

The results of the appropriate infusion of data into care delivery processes have been diverse—and beneficial to the organization both clinically and financially. For example, providing the organization’s physicians with real-time data-driven dashboards has helped those doctors to successfully achieve clinical outcomes goals across a wide variety of measures around diabetes, asthma, and prenatal care, and around the avoidance of ED visits and hospital admissions. And as a result, Olivares reports, “By achieving all the measures on the risk-based contracts we have, we received $1.6 million in differential payments last year.” What’s more, he notes, “It took us 18 months to get Level 3 recognition from NCQA [the National Committee for Quality Assurance]; we were accredited early last year. By achieving the Level 3 NCQA recognition, we generated $3.50 PMPM [per member per month], which translated into $3 million in incentive payments from our payers,” who include Medicaid managed care and some commercial health plans.

Data-driven care delivery has not only been profitable for the organization; it has also positively changed the way in which physicians work, reports Ross Ronish, M.D., YVFWC’s chief medical officer. “Physicians are trained to be pattern recognizers, and there are some strengths to that, but one of the weaknesses of it is that what is in your mind as a provider is what you’ve last seen,” he says.  “So if you ask physicians how they’re doing with their patients in general, they’ll look at their most recent patients, and will be wildly wrong. So using IT to provide a current picture for physicians will help tremendously.”

Dashboards are essential to helping physicians to dramatically improve their clinical outcomes and efficiency in a resource-straitened environment, Ronish says. What’s more, their use helps all clinicians to work at the top of their license, he adds. “For example, we use behavioral health consultants, or BHCs, who work within our medical clinics, and who help providers to identify when psychosocial conditions are affecting patients and their outcomes, and  helping to address things when, say a PCP is tempted to call a patient non-compliant,” he says. BHCs actively analyze the patient record for narcotic use patterns, and benefit from being able to draw from medical, behavioral, and other data, drawn into the same systems. In one recent case, he notes, a BHC was able to clarify that middle-aged male patient was not non-compliant in taking his medications, but rather, suffering from a personality disorder, the clear identification of which necessitated a new medication management strategy. Having dashboards in place to analyze the use of narcotics for chronic pain makes such interventions possible, he emphasizes.

Indeed, says Glen Davis, YVFWC’s chief operations officer, “The [information] system that we had been operating under for years involved a separation between clinical, social, psychological, issues, when they’re really not separate. A dietary issue can cause either a behavioral issue or a medical concern or a dental concern, and systems are starting to show more of the psychosocial elements,” he adds. “So we don’t just do this with our behavioral health consultants; we also have dieticians who follow the very same model. And we’re fortunate enough to have dental and pharmacy connected as well, all connecting the dots.”

All of this data-connected care has been very important in the forward evolution of the Yakima organization. “As a result of a lot of this work, 95 percent of all our providers met all the meaningful use criteria for Stage 1 years 1 and 2; now we’re heading into Stage 2,” notes Davis. “And within 18 months, we achieved level 3 recognition from NCQA,” underscores. The organization is also converting to a new electronic medical record, which will go live in August.

With regard to all the IT investments, Olivares says that “We knew we had to invest in the development of a data warehouse not only encompassing our EMR, but also pharmacy, dental, behavioral health; we have other types of systems that help us understand the condition of our patients, not solely restricted to the EMR. So we built that data warehouse to allow us to pull out data in a meaningful, actionable way. So we had to build out patient registries. For diabetics, for example, we needed to know what had happened to them before they came to see us. If they had gone to see the nephrologist, we needed to know that and know what happened. And that’s through claims data. So we started to combine a whole host of information on the registries, to give our entire clinical care team an assessment of where this patient was today, and what we needed to do today to improve his care and outcome.

The key to understanding the landscape in which the Yakima Valley folks work lies in understanding how much everything is in motion these days. First, there is the health status of their population; Olivares notes that clinic leaders have recorded a 22-percent increase in identified obesity just in the past year, for example. Second, there is the opportunity that has opened up under the Affordable Care Act (ACA), through its Medicaid expansion provision. Both Washington and Oregon have gone ahead and expanded their Medicaid programs, and with 70 percent of YVFWC’s patients being Medicaid enrollees, there is a great deal of potential for the clinic going forward, he says, though he immediately notes that many of those patients are already on a sliding fee scale because of their low incomes, and also, very importantly, that essentially, the Medicaid program is increasingly becoming, state by state, essentially a large managed care program, overall.

Still, there is right now a genuine opportunity to increase the insured patient base in the Yakima Valley, and the YVFWC’s leaders are doing everything possible to build that base. Last year, Olivares reports, “We created health fairs, school information, roundtables, we went to churches. We explained what healthcare reform was about. We got about 3,000 new patients in Washington, and got about 4,000-5,000 new patients in Oregon. And in both of the states in which we operate, somewhere around 90 percent of those eligible for Medicaid are in Medicaid, and all are in a managed care environment. So the states of Washington and Oregon have contracted with managed care systems to address the needs of those who are Medicaid-eligible.”

In other words, the opportunities abound to increase their patient base, but those opportunities are constrained by the fact that the vast majority of new patients YVFWC might attract will be Medicaid enrollees or potential Medicaid enrollees, and nearly all of those will be in Medicaid managed care, one of the most resource-limited populations to care for. So everything does circle back to the intelligent leveraging of analytics, clinical decision support, and other tools, to engage in population health management strategies around a population lacking in financial resources.

In the end, Olivares, Ronish, and Davis remain fiercely committed to caring for and serving that population, but they recognize the breadth of the challenge involved. “This elephant is indeed an elephant,” Olivares muses. “And if you try to swallow it all at once, you’ll find yourselves overwhelmed. But if you’re willing to take risk in a managed care environment, and are willing to leverage data to do so, believing that you can improve patient outcomes, then you can do this, taking the elephant one bite at a time. Find a good partner like Arcadia that will work with you to analyze everything. And,” he adds, “don’t be afraid to fail.”


March 19, 2015