In “The state of American healthcare”, I shared that American healthcare remains complex and expensive compared to other developed nations. I also shared how the interests of payers and providers are aligning. With this as a backdrop, I wanted an example that could be a guiding North Star to both payers and providers. I found this in a recent interview with Robert Van Tuyl, the Chief Innovation Officer (CINO) for Easterseals Bay Area (ESBA). In this post, I describe the challenges that they faced and how the ESBA team created a new way forward for healthcare.
Background on the initiative
Easterseals is a national not-for-profit organization that will be 100 years old in 2019, serves people and families facing a range of long-term physical and mental health disabilities. ESBA was a traditional affiliate with about $6 million in donor-based revenue until a few years ago. However, in 2012, the law changed for behavioral services in California. With the stroke of a pen, insurance companies were required to provide healthcare for individuals diagnosed with ASD (autism spectrum disorder) and other pervasive developmental disorders.
This change dramatically increased demand for the healthcare services ESBA specialized in. Given this, ESBA partnered with Kaiser Permanente to help provide behavioral services to Kaiser Permanente’s members. In this process, ESBA quickly learned that the provider market within the Bay Area was fragmented with many different provider companies – everything from small ‘mom-and-pops’ to larger firms.
Robert’s work at ESBA began in December of 2012. His immediate goal was to build the infrastructure and capabilities needed to handle the influx of clients they needed to manage. ESBA needed to scale up the home-based and clinic-based services. Historically, they had served less than 200 clients — now they needed to serve thousands of clients.
“The sheer client referral volume that we had to handle for these services was totally new to us,” Robert says. The change grew ESBA into an organization that not only provides services but acts as a health services network manager. Now, their network provider function eclipses the clinical services they provide directly. ESBA is managing about $200 million in healthcare services this fiscal year. To do this, they hired more than 300 direct care providers and manage a network of nearly 5,000 sub-contracted healthcare practitioners, tracking quality, clinical outcomes, revenue-cycle management, invoice, billing and other payment processes.
“There’s about 106 companies sub-contracted in the network that employ nearly 5,000 healthcare practitioners,” Robert says. These healthcare provider companies service about 90,000 appointments a month. To manage such volumes, the ESBA team needed to create a technology framework that could stitch together this diverse ecosystem of healthcare providers.
Making network management real
To create an environment capable of responding to the demand for behavioral healthcare services in northern California, Robert needed to bring together internally and externally created technology. This included seeking new technology and approaches before they were available in products.
For this reason, ESBA started working with Salesforce prior to its 2015 Salesforce Health Cloud product launch. Robert saw the opportunity to put together a new type of healthcare system better focused on the client. He wanted to reimagine healthcare provider and payer relationships. Given this, Robert says he and his team were actively involved in Salesforce Health Cloud’s roadmap and was one of its earliest customers.
ESBA now uses Salesforce Health Cloud for case management and care coordination lifecycles, as well as critical enterprise business functions such as a referral management, authorization management, call center management and end-to-end management of the BHPN (the Behavioral Health Provider Network). Everything flows through Health Cloud. Robert says he is continuing to look at how Salesforce Health Cloud can change how ESBA delivers its services. For this reason, he is actively working to ensure product roadmaps move in the right direction.
At the same time, Robert says they are building their own products on top of Salesforce Health Cloud including mobile applications. Robert says ESBA wanted a robust, scalable infrastructure that could expand from a pure electronic health record (EHR) and revenue cycle management (RCM) perspective. And that’s where the integration with the Athenahealth EHR came into play.
This was a critical step because much of their revenue cycle management, including generation of the explanation of benefits (EOB) and statement reconciliation, including payments from the clients, is managed through Athenahealth. Because of the uniqueness of the clientele that they serve and the varied custom care plans, Robert’s team had to implement workflows for pre-processing of claims even before they are entered into Athenahealth. The proper coding and quality processes are steps his team ensures are done to the highest degree.
Robert openly shares that none of this would be possible without putting in place a data integration and data mastering capability. Robert said that ESBA took advantage of the various adaptors that were off-the-shelf. ESBA also took advantage of Athena’s custom adaptors for EDI transactions. And the organization used Dell Boomi for integrating everything back into Salesforce Health Cloud when there wasn’t a prebuild API. So, he says they leveraged Boomi very expansively.
Robert said that ESBA manages the entire pre-authorization process. They have products built on top of Salesforce Health Cloud that aid claims management. ESBA has built various different business rules in Health Cloud that check for authorized hours delivered, duplicate delivery, and encounter accuracy during the pre-processing stage of the claims submission process. With these validation rules completed, encounter data moves through Dell Boomi’s transformation and transport layer to Athena Health’s revenue cycle management engine for final claims processing.
The biggest validation of his work, according to Robert, is not just the volume of transactions ESBA can support, but more importantly that the ESBA healthcare network has passed rigorous audits from Kaiser Permanente and other organizations. “So, scaling is one thing. Scaling with HIPAA compliance and passing a Kaiser Permanente’s Program audit are two different things,” Robert says.
Client outcomes is really where it’s at
When you can put all of this data together, Robert says you can deliver on the promise of a 360-degree view of the client experience. He always talks about the client in terms of context of outcomes. For ESBA, this is about making all key data available to the right care teams and individuals, including care coordinators, case managers, and the in-home care providers who participate in the care cycle. ESBA’s digital infrastructure allows for all caretakers to effectively participate in the care cycle with the end goal being better outcomes for the client while improving the efficiency of home and community-based health services.
What I find empowering in Robert’s example is how he acted as a catalyst for strategic change at Easterseals Bay Area. He achieved business relevance by driving the realization of business strategy and business opportunity. This is a model forward for all CIOs who want relevance. In healthcare, it represents the actions of a true trailblazer.