Lynn Kryfke, RN, MSN, executive direct at Children’s Community Health Plan, and Sumant Rao, senior vice president of performance analytics at Cotiviti, discuss their renewed partnership and highlight what health plans can learn from their combined successes and challenges.
Please tell us a about yourself and your background at each of your companies.
LK: I have a bachelor’s of science in nursing, and a master’s degree in health care systems with systems leadership from Marquette University.
I’ve been working in the children’s system for almost 11 years, and at Children’s Community Health Plan (CCHP) for 9 of those years. I’ve been in my current role for almost 8 years as a director of health plan clinical services, and then as the executive director with increasing span and responsibility.
I oversee utilization management, case management, complex case and disease management, quality improvement, and risk adjustment. I’m responsible organizationally for quality, risk adjustment, and accreditation.
Our health plan started out offering Medicaid in Wisconsin in 2006. In 2017, we added our marketplace and commercial products. We pride ourselves as being local, part of the community, and a not-for-profit. We offer Medicaid, marketplace, and commercial products. We have approximately 125,000 Medicaid member lives and about 11,500 marketplace and commercial members, in the state of Wisconsin only.
SR: I’m the senior vice president of performance analytics. I’ve been with Cotiviti for 6 years and have seen the transition from Verisk Health to Verscend to Cotiviti. I’m a computer engineer by training with a master’s in business administration.
In my current role, I oversee the business units for some of our verticals, which focus on quality— primarily HEDIS focused population health—a new acquisition that we just made around network value, which is all around provider profiling and position scoring.
I also look at our enterprise data management function. Given the size of the organization, we have a really large data footprint and to assess all the pipes that bring that data in every day is something that one of my teams manages.
I also lead one of our innovation initiatives around the data lake, because again, given the size of the data footprint, we are sitting with access to large sets of data across different domains of business. We, as an organization, are trying to see how we can leverage this data better for our clients to actually get more value.
We’ll talk a little bit about that later, but that’s the other piece that I oversee. It’s really a combination of the business function across quality and performance, enterprise data management operationally, and then innovation on the data lake.
Can you briefly highlight your partnership together, and how this partnership originally began?
LK: As Sumant said, it was originally Verisk Health, then Verscend, and now Cotiviti. I believe that we’ve been a client for close to 10 years. We licensed the tool and rolled it out to several departments at that time. We have worked over that time to learn about the functionality of the tool and how to best utilize all the features and information. There’s a lot of information in the tool.
The COO of the health plan, originally licensed the tool, so it was before I was in this role, but I’ve immersed myself in learning the tool and have utilized it, along with the medical director, my team of leaders, to really dig into it, learn about it, and use it for our business. It’s really been helpful over time.
SR: It’s been a very long relationship and still is evolving.
Can you highlight why you are renewing your partnership and what you hope to accomplish?
LK: From my perspective, the Cotiviti products meet our needs currently. The risk stratification is integral to identification of members that may be in need of complex case or disease management.
We can identify different patient populations who may be high utilizers or members with care gaps. We use their tools to stratify and identify populations at risk, track, and trend cost utilization metrics.
We share the information with provider groups, so we teach them how to use the tool and support them so they can look at their population utilization, their risks, and their trends. We have been giving access to providers for several years on their patient panels, because this data is not available to them from any other source.
Just recently, we’ve actually started using the tool and reporting on a system value-based arrangement. The tool has really been useful to us here at CCHP.
One of the other things that I wanted to share is why we are renewing. Cotiviti is willing to incorporate custom fields into the tool to help us gather needed information to better assist our members.
For example, Sumant and I were just talking about— and prior to that, our client representative from Cotiviti— they’re willing to add the Z codes.
The Z codes describe social determinants of health, which for us, serving vulnerable populations, it’s really important to gather that information because it really does have an impact on overall health and participation in health care.
The other thing that they’ve been helpful in is supporting our primary care attribution logic, which was really unique to us here at CCHP, I believe.
SR: In terms of, again, we’re really glad CCHP is part of the ecosystem. There are certain things that we’ve been working on as an organization to get us as in a position to address business problems that not everyone wants to solve.
An example is serving the vulnerable population. How do we do this? These are questions that people have asked for a while.
We have theories, beliefs, and statistical concepts that we think we know, but without a strong partner in the field going through these processes every single day, it’s hard for us to innovate.
The big plus, as a result of the expansion, is tightly connected in that some of the concepts that we have built, especially around social determinants of health, are on opioids. Some of these concepts that we have built, we really want to get it out in the field and see how it’s working.
How does this partnership improve both care management and quality for all parties involved, including the provider, payer, and patient?
LK: From my perspective, as I commented before, just identifying the entire clinical picture, including the care gaps from a quality standpoint what is the member missing? It’s easily accessible to staff on an individual basis or in an aggregate.
Reports are really easy to run on the tool. You can build a query and get that actual population that you want. We can easily identify the member’s primary care provider. That’s a CCHP perspective.
What can other health plans learn from your relationship?
LK: One of the biggest things is the staff at Cotiviti. They listen to what the customer needs, and they make accommodations to meet those needs.
When we’ve needed primary care provider attribution logic to support our value-based contracts, Cotiviti did it for us. When I asked about Z codes, they said to me, “We could probably put a customized field in there to pull that code in so you can really see the entire member experience.”
For us, it’s the willingness to listen to what we have to say, to help us meet our needs. That’s why we’re continuing in this relationship.
SR: Thanks, Lynn, that’s great. That’s one of the things that been a focus for us as an organization, as well as, a lot of ideas. We think we know a lot of things, but it’s so important to stay connected with our clients and get that feedback.
What we’re seeing, interestingly, is that you’re limited by imagination right now. With the kind of big data infrastructure that we’ve put in place, with the data science we have in place, we really want to push the boundaries on extreme years in terms of how we can innovate, and how we can drive solutions to the market.
Having a partner, like Lynn, especially, is really beneficial. Constantly listening to plans for what problems they need us to solve, getting that feedback, and us as a team, as basically a science team, figuring out how we can solve these problems.
We’re also not limited from a technology architecture perspective, so when someone says, “We are interested in these additional fields,” or, “We’d like you to bring this data in, can you do it?” When we say yes, it’s because we want to work with you.
We want to make sure that we don’t let an old technology get in the way.
I’m really glad to hear this feedback, because that’s something we’ve been working toward consistently. We are at a place where, at this point, we just want to innovate together.
What challenges did you face when first partnering, and what can other health plans learn from your challenges if they were to implement a partnership similar to yours?
LK: For us, it was learning what was in the software application, and how to create the reports to demonstrate what we were actually looking for. We, as a health plan, needed to invest the time to train the staff and leaders.
For me, what I really like about the tool is I can use it. It is intuitive and you don’t have to have an IT background. It is just a matter of learning about what’s actually in the application and there is a wealth of information.
It’s worth making the investment to train the staff so they can get in there, because once they get in there, and they realize how easy it is to use, they can use it on a daily basis when they’re working with their members.
SR: I think that’s the crux, actually. I call it the BI [business intelligence] journey, but there needs to be a commitment to using and leveraging technology to actually get the insights.
A lot of our thinking is led by the payers who are committed to the process. To echo what was said earlier in terms of, “Make sure you take the time. Make sure there’s enough investment in training, and to trust the output and to act upon it is really critical.”
What I’ve seen with some of the other health plans—and we’ve got a whole spectrum that we operate with—is that there is always a tendency, initially, to be impatient, to say, “I don’t trust this. I’m going to do this myself.”
You will find, in most mid-size health plans, that they have built up their own informatics groups of around 20 to 40 people doing exactly what the software does, but doing it independently.
I think the shift from thinking about the “not invented here” mentality to actually saying, “What can I do with data? How can it solve my business?” The ones who are successful are the ones who are saying, “I’ve got these insights. Let’s talk, and let’s solve business problems.”
The ones who are still lagging behind in innovation, the BI space, or the science space, are the ones who are more interested in making the widget than actually defining what the widget is.
If there’s one thing that any health plans will learn up front, it’s to take the time, make the investment, focus hard on what the business problems are. Leave the technology and the science to people who do that for a living. Focus on understanding the business, because no one understands the business better than the health plan does. I think that’s one.
The other part of it is, you cannot push for perfection in data. This is health care. You will have data issues. It’s always the way it is. There’s a history behind this.
Our whole industry, at the end of the day, is a series of acquisitions, and thus, a series of old systems that are trying hard to modernize.
We live and breathe data every day, and we’ve seen cases where without a 100% data accuracy metric, people do not move into reacting on insights. I think that’s fundamentally flawed, because even at a 95%, 98% accuracy level, you have enough insight at a population level to inform a decision.
But we’ve seen structures which are refusing to say, no, they are going to be super clean, in which case, you’re probably going to have to wait a really long time before you can start moving with BI. This is not just our clients. This is generally an industry observation.
One piece, apart from being focused on business and then taking to time to invest in technology, the other piece is that you’ve got to set up a minimum threshold of information that you can react to, and so waiting for everything to be laid out neatly
What are each of you most excited about in this relationship renewal?
LK: From my perspective, I met Sumant, and he was telling me about some of the new things that I didn’t know about, opioids, which we struggle with and the social determinants of health, the new features, the addition of those social determinants of health, to get a more holistic view of the member.
Increased ability to customize or add fields and use the software application to further support our value-based arrangement, and presenting the information and allowing providers the enhanced information in the tool will only help us to partner better.
I’m really excited about that and moving forward with all of this new information.
SR: I’d echo that. I think the ability for us to have a partner who’s willing to push boundaries a bit on the innovation side of it is completely worth it.
We have a few things that we are cooking up now with Lynn’s team, and I’m pretty sure it’s going to benefit the community. That’s what I’m really excited about.
Finally, is there anything you would like to add?
SR: I’ve got a few things, and I think it’s important. Again, I’m harping on a theme of constantly how we push the boundaries, because as an organization, we’ve grown so much. The way I look at growth is what kind of assets do we have today?
If you look at everything from a data side perspective—including, of course, integration—we probably will have one of the largest databases in the country across covered life.
It’s interesting, because the data that we have is not only risk. It’s not only HEDIS. It’s a combination of HCC classifications, payment scores, provider profiles, network scores. There’s a whole variety of domains that get added to the data, which is where, I think, as an organization, we’re really excited about where we are headed as far as innovation is going.
The approach we have consciously taken is to work with a select few of our partners and keep pushing, but not get overly distracted trying out every single new thing. Right now, it’s incredibly exciting.
It’s a nice pace for us as an organization, and I hope to share the excitement of our key clients, too.