With or without COVID-19, we will transform the care delivery system

Dr. Sanjay Doddamani is chief operating officer and chief physician executive at Southwestern Health Resources, a clinically integrated network comprising independent community practices together with Texas Health Resources and the University of Texas Southwestern Medical Center in the Dallas-Fort Worth area. He started in his role in mid-March, just weeks before President Donald Trump declared a national emergency because of the COVID-19 outbreak. He previously served as senior physician adviser at the Center for Medicare and Medicaid Innovation and was chief medical officer for the accountable care organization and the home-based program at Geisinger Health.

He recently spoke with Assistant Managing Editor David May about Southwestern’s experience and the network’s approach to dealing with the pandemic and the organization’s emphasis on value-based care. The network has been in the Next Gen ACO program since 2016 in addition to participating with major payers in fully capitated arrangements and owning its own Medicare Advantage plan.

MH: How was Southwestern formed and how is it structured?

Doddamani: Southwestern Health Resources was born of two entities in 2016. Texas Health Resources, which is a 29-hospital faith-based community-based system, and University of Texas Southwestern Medical Center, a premier academic medical center system. We have several thousand community-affiliated primary and specialty providers. We have the UT health system and its providers, plus Texas Health Resources and its primary-care group in the mix. So almost 5,000 physicians. And then an incremental number of nurses and advanced-practice providers supporting the network, all representing a total of more than 700,000 lives.

MH: Can you walk us through the trajectory of dealing with COVID-19? And who do you serve?

Doddamani: In the early days of COVID-19, following the president’s emergency declaration, as a value-based care organization we were very quick to respond. Within about 96 hours, we turned around almost 750 of our employees to work remotely. It was a Herculean task, moving people out of embedded clinics and working remotely. Within days we mobilized our entire workforce to work remotely, from 11 locations.

With the network’s patients, we have roughly 200,000 lives that are either Medicare or in some form of Medicare Advantage plan where we are at full risk. We then have almost 400,000 commercial lives that we support. So our social workers, our team’s managers, most of whom are RNs, the broader team, including our call centers, all of them were either in the office or in the practice. They all had to essentially replicate their services by performing remotely. We used some interesting collaborations to help facilitate our operations. For example, we teamed up with a home-health company to be able to deliver our vital care packages that were really helpful to seniors.

MH: There has been some been some ebb and flow in the COVID caseload since those early peaks. But what’s going on now in Texas, given the surge in cases during the past few weeks?

Doddamani: Dallas-Fort Worth has one of the highest positivity rates among U.S. metro areas. In some parts of Texas, the rate a single day has tripled such as in Houston. Rates in Texas approached 7,000 cases in a single day. Government officials have reinforced wearing masks and to practice social distancing and the governor recently warned of lockdowns as a last resort. We are making sure that we are doubling down on accurate messaging to patients, especially those at higher risk. We are ensuring safety at home, activation of emergency services when needed, even for non-COVID conditions since there has been a dramatic rise in cardiac arrests and at home deaths, presumably from strokes and heart attacks. Overall, I think we can put to rest the doubt that wearing a mask helps and so does social distancing along with hand-washing and self-quarantining, as well as testing.

MH: You’ve started reopening elective services and other routine care, correct? Are you still moving forward?

Doddamani: Subject to capacity that is reviewed on a daily basis, our parent facilities have successfully launched safe restart programs. They are continually in touch with patients so that no one’s competing for beds. At this moment parent facilities still have capacity in terms of ventilators and ICU beds, but if this continues at the current rate, we are going to, probably within weeks to under a month, be faced with a more dire situation. So we cannot underscore the governor’s messaging around social distancing and masking enough—which is very important to keep the denizens of Texas safe. We are amplifying that message in English and Spanish.

MH: How have your network’s capabilities been deployed during the pandemic?

Doddamani: Our vast access to data provided insights. Most population-based companies are looking for care gaps, such as those who didn’t get a flu shot and where there’s anemia or whether it’s medical complexity or who the right patients are to be receiving palliative care and things like that. All that data can help identify patients who have chronic conditions such as heart failure and so on. We went a step further to use our data insights and innovation to help identify those at risk for COVID depending on their zip code, their risk susceptibility, given underlying conditions such as cancer or other immune-compromised conditions, even poverty and social determinants.

We have a large social determinants team that provided enhanced education. We have a large population of patients who received communications from us, both in English and Spanish, that help to amplify the messaging around social distancing, wearing masks, hand-washing, self-quarantining when ill or suspected to be ill.

We also have seen that many patients stopped undergoing screening tests. There was obviously a dramatic reduction in elective surgeries and procedures, and there’s been a lot of buzz about how much of this is warranted versus overused. But from our standpoint, the most important thing is keeping patients safe. So when we saw a 164% increase in the “dead-on-scene” numbers, which is ambulances showing up to patient’s homes who had passed away suddenly, and that was not COVID-related, the majority of those were heart attacks, strokes, other sudden acute events. It really meant that we needed to take a deeper look to see whether our hospitals also were seeing a dramatic reduction in activation of the cath lab for emergencies.

And it was true, there was a 38% reduction in what we call STEMI activation (for heart attack). There was also a decrease in strokes presenting to the ED. Our job there is to identify all those patients with uncontrolled hypertension, with diabetes, those with other risk factors for heart attacks and strokes such as not being on high-intensity statins, where they have underlying, serious risk. And to get out to them and make sure that they knew that they needed to seek emergency medical care, not delay care, given their symptoms. It gave us a real opportunity to find our relevance amid the pandemic.

MH: Tell us about the emphasis on value-based care. How has it helped in your organization’s efforts to address the pandemic?

Doddamani: When we talk about value-based care, I think what comes to mind is that there needs to be a 100% total alignment with financial incentives, quality patient experience and outcomes. And I think, from a network perspective, our job has been very clear. COVID or no COVID, we are going to transform the care delivery system by investing and supporting and aligning physicians with the mission and direction that value-based care is offering.

The most important thing for us is that physicians understand that you can have high-quality care that costs less and produces superior outcomes. And one tangible example during COVID-19 is, when many of the primary-care practices are struggling to keep their lights on and pay their staff. We accelerated and moved up our quality and performance incentive payments that would come to them in the fall and in the new year.

We moved all of those payments up to pay them in May, and may do a second round of financial-incentive payments so that we can be helping them focus on care, focus on the right things to do and aligning their care delivery with value-based care principles and helping to facilitate the flow of funds uninterrupted. And I’ll tell you that many physicians who are not part of (a value-based) arrangement are hurting even more than those who have built-in financial incentives for quality and performance, such as the physicians who are part of our clinically integrated network.

MH: Value-based care has been somewhat slow to gain traction. How do you see that changing?

Doddamani: I have been very sold on value-based care. Having worked at Geisinger, having seen firsthand how effective new care delivery models are, having worked at CMMI and seeing the potential of things that have been developed there through alternative payment models. So I think fee-for-service in its current iteration at least has proven during a pandemic that it will not further care, it will not sustain healthcare. And not only will we go bust sooner, it really doesn’t even meet the objectives of patients with the greatest need, nor does it support the resources development that, for example, Southwestern has been able use to take better care of patients through better support of providers. Whether it’s through data, whether it’s through care coordination, whether it’s through social work, it’s all expensive and really takes a level of expertise and resources.

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