RamaOnHealthcare April 9, 2022

Today, RamaOnHealthcare talks with Tom Ferry, President and CEO, Engooden Health on redefining Chronic Care Management (CCM).

Tom discusses the rising number of patients with chronic diseases in America and how Engooden Health is helping providers close gaps in care by reaching patients with multiple chronic diseases between office visits. He also explains how scalable, technology-enhanced chronic disease management programs are crucial to improving health outcomes, why actually engaging patients is essential to success, and how Engooden Health is helping providers overcome healthcare worker shortages while lowering the overall cost of care.

Tom Ferry, CEO and President of Engooden Health

Tom Ferry, CEO and President of Engooden Health

RamaOnHealthcare (ROH): What challenges in the healthcare industry led to the formation of Engooden Health?

Tom Ferry (TF): There are two huge challenges that Engooden Health is trying to address – one related to patients and the other related to providers. The number of people with chronic disease – and particularly more than one – is growing fast, and so is the number of people aging into Medicare each year. One in four American adults and 66% of Medicare beneficiaries have two or more chronic conditions, and the Medicare population grows by 1.5 million people each year. At the same time, there are fewer primary care providers to take care of that growing population. There’s also the reality that more clinicians are leaving the field. All of these factors are contributing to a perfect storm that is overwhelming the healthcare industry. Meanwhile, the patient experience continues to deteriorate.

Another compounding factor is that clinicians today face the impossible: they own 100% of the responsibility for patient outcomes, and yet they only see those patients during regular — and brief — clinical checkups. Meanwhile, 80% of the patient outcome is influenced by factors outside of provider interactions – socioeconomic status, caregiving status, and health habits – which all play a bigger role in health outcomes than clinical care. There is limited infrastructure available to help providers maintain consistent insight into the patient’s life and health outside of clinical interactions, leaving a gaping hole in the healthcare industry’s care delivery model.

There is limited infrastructure available to help providers maintain consistent insight into the patient’s life and health outside of clinical interactions, leaving a gaping hole in the healthcare industry’s care delivery model.

There is an enormous opportunity to improve healthcare and provide more trusted and empathetic support to patients between office visits, and that’s where Engooden Health comes in. Today, a substantial portion of the patient population feels neglected and frustrated by a very complex, confusing, and overburdened healthcare system. The infrastructure to help them manage or improve their conditions at home simply doesn’t exist. At Engooden Health, we saw an opportunity to leverage the Centers for Medicare & Medicaid Services (CMS) Chronic Care Management (CCM) reimbursement program to develop technology-enhanced services to help providers care for this ever-growing patient population. Once we got started, we realized that our program doesn’t have to be exclusive to the Medicare fee-for-service population – we can help so many more people. It’s an opportunity to deliver a new standard of care to every patient.

Our approach is focused on rising-risk patients – a significant population that is often difficult to reach. We find them and talk to them between office visits and the support we provide changes the trajectory of their health outcomes and, in many cases, improves their overall quality of life. We also keep them out of the more expensive and harder to manage high-risk population.

ROH: Providers are responsible for 100% of patient outcomes; however, some factors influence patient health beyond the walls of the doctor’s office. Research suggests that 80% of health outcomes are affected by non-clinical factors. What are some of the core reasons providers have not historically addressed these elements?

TF: Many non-clinical factors, such as where a patient lives or whether they have transportation or food in the house, can dramatically impact health equity and patient health trajectories. But our healthcare system is not built in a way that allows physicians to offer personalized, hands-on, individual care to each patient. Screening for these social determinants is not practical for a physician who has thousands of patients. Clinicians simply do not have enough time or resources to truly learn everything about their patients and uncover factors outside their control.

From a patient’s perspective, overcoming health obstacles often feels impossible. Some must decide between putting food on the table for their family or paying for medication that will help them manage a chronic illness. Some might care for elderly parents, a sick spouse, or a disabled child, which makes finding the time to exercise – or do anything else – very difficult. In that case, asking a patient to lose 15 pounds is asking for a lot. But with consistent coaching, and a better understanding of barriers to health, Engooden Health care navigators can adjust those goals to make them more attainable. Instead of focusing on what seems like an impossible goal (lose 15lbs), our care navigators will begin with getting a patient to walk to the mailbox one day, and then around the block a few weeks later, and allow the patient to see how those small steps can make the big change possible.

Another obstacle in the healthcare delivery system is identifying resources and connecting patients with the unique services and support that will help them overcome health barriers and improve their quality of life. The dots don’t always get connected. As a result, there is an appetite to establish a model that encourages providers to embrace health equity and partner with organizations like Engooden Health. We work with our provider partners to understand what resources are available to patients and then we use those resources to meet patient needs.

ROH: CMS continues to invest in CCM and related programs, significantly increasing reimbursement for providers. This is clearly indicative of confidence in CCM programs’ ability to improve patient outcomes. Even if we see CCM embraced more widely, do you think this is enough to repair what you’ve identified as a broken and unmanaged model?

TF: While CCM is critical to improving patient outcomes, it is just scratching the surface. With more patients getting sick and aging into Medicare, the only way to address the tidal wave coming for the industry is to create a more personalized approach to patient care.

With more patients getting sick and aging into Medicare, the only way to address the tidal wave coming for the industry is to create a more personalized approach to patient care.

Qualifying for CCM reimbursements only requires documenting 20 minutes of work with a patient each month, but it’s not enough. At Engooden Health, we go beyond CCM’s minimal requirements. We commit to speaking with patients directly each month and don’t bill unless we do. If we’re not speaking to patients on a regular monthly basis, we won’t get the insights we need to identify the obstacles and roadblocks that keep them from taking their medication, exercising, or eating the right foods.

Finding the resources to scale and deliver a higher caliber of care to all eligible patients is difficult for most providers and networks, but it’s what we do at Engooden Health. Our care navigators spend as much time as they need to help remove the many obstacles patients face. Not only do we call patients every month, but we also look for solutions. We research food banks, find lower-cost pharmacies or medications, and partner with our customers to make sure we know about the social determinants of health services they offer and any local providers they recommend. Spending all this time with patients allows us to build and gain trust. Without trust, the program doesn’t work.

We believe having the ability to establish the foundation of our program through CMS is a great thing, but moving the needle requires the larger payers to see the benefit of building the infrastructure.

ROH: You mentioned the ability to scale CCM is a major pain point. How does Engooden Health help address this specific challenge faced by both small practices and larger provider networks?

TF: We built the technology, and we hire, train, and support teams of care navigators to support each customer’s patient population. Over time, we’ve established a model that allows our care navigators to reach the right patients at the right time and spend as much or as little time as they need for each patient, each month. For some patients, it’s a brief check-in and discussion of the care plan; other patients require more time – and some need more than one call each month. And that’s ok. We don’t bill for services unless we speak with a patient and our platform is integrated with each provider EHR so that follow-up discussions around chronic disease management services can happen during provider visits, too.

Finding and hiring the right people for CCM services are challenging. Not only do they require a unique skill set, but we’re still in the midst of a healthcare staffing crisis. Some vendors offer CCM technology, but require the provider to manage and staff the program themselves, which is unsustainable.

Engooden Health is unique in that we manage the program entirely, so providers have no new technology to learn or staff to hire. And to operate at scale, care navigators need the right patient information fed to them at the right time so they know where to focus. That’s where our technology comes in. Our technology analyzes EHR records to recognize chronic conditions to identify more CCM-eligible patients. It provides actionable data insights from the EHR that are automatically surfaced to care navigators, allowing them to focus on the most clinically important updates.

We believe scalable CCM requires marrying technology with the right profile of healthcare professionals. For us, that’s someone who is patient, empathetic, and inquisitive. It’s someone who wants to really help people and build a genuine level of trust with patients. And it’s someone who can be creative in solving problems. Engooden Health’s technology-enhanced service lets our care navigators spend time with significantly more patients, creating a complete picture of their health and barriers to care. And, because our platform integrates seamlessly with EHRs such as Athena, Epic, and others, deploying and ramping up is efficient and straightforward.

ROH: How do Engooden Health’s services work across fee-for-service and value-based care models?

TF: We started with fee-for-service models because the Medicare Chronic Care Management program provides a structure for us to demonstrate how quickly we can implement and make an impact with patients while providing returns directly to physicians. We can manage high volumes, reduce turnover and enrollments, and maintain high engagement with patients.

If you look across our panel of customers that use our tech-enhanced services for their Medicare Chronic Care Management population, we generate about $22,000 in additional net revenue per physician each year. For a practice with 10 physicians, that’s $225,000 in additional net revenue. We also frequently see that our care navigators help retain patients who may have otherwise left a practice if not for the services we provide. If we save just 1% of a physician’s patients, that’s an additional $5,000, or $50,000 for a practice with 10 physicians. Again, that is money that Medicare reimburses the practice for offering CCM services to its patients.

Lowering the cost of care while improving quality is the goal for most value-based, risk-bearing provider organizations. Based on the success we’ve had with fee-for-service clients, we’re starting to work with more value-based care organizations to help lower the overall cost of care while providing tech-enhanced services to broader populations of patients.

ROH: Can you share insight on some of the improved patient outcomes you and your team are seeing?

TF: Improving overall health is the goal, and we have reason to believe that our program is doing that – while lowering the overall cost of care. For example, we often see that our care navigators are able to help patients reduce A1c levels, in some cases to pre-diabetic or normal levels. According to the American Diabetes Association, people with diagnosed diabetes have medical expenditures approximately 2.3 times higher than those without diabetes. Through consistent coaching, education, and encouragement for diabetes patients, we estimate our program saves roughly $8,000 per patient each year for those we can successfully manage down to pre-diabetic levels. Patient health outcomes are exciting to see. In addition to helping with diabetes, we’re also helping patients reduce blood pressure, weight, total cholesterol, and more.

One patient we work with is a 78-year-old woman with hypertension and depression whose blood pressure was 150/100 when we started working with her. After only four months of CCM with Engooden Health, she lost 16 pounds, and her blood pressure came down to a much healthier 108/68. Consistent engagement is instrumental in achieving results like this. We have hundreds of examples of how we’re getting patients on track with care plans and helping them take control of their own conditions. Whether it’s clinical outcomes like the story above or simply providing that personal touchpoint each month for the many patients who experience loneliness or depression, the trust our care navigators build with patients allows them to uncover significantly more information about a patient’s full health status, including some that might not otherwise surface.

In our experience, physicians want to provide the best care they can to their patients. Engooden Health helps providers achieve that goal without adding staff. For example, our customer Bluestem Health in Lincoln, Nebraska, tried to implement their own CCM service and did not find it to be worth the investment. As a result, they were unsure about engaging with Engooden Health. Within 90 days, we enrolled half of their eligible population. Engooden Health care navigators provide patient education, medication interventions, and more, and Bluestem is getting patients back into the office at the right time when areas of concern are flagged. We’re thrilled to work with provider partners to reach more patients, keep them engaged, and ultimately improve the lives of those living with chronic diseases.

About Thomas Ferry

Tom joined Engooden as President and CEO after two years as a member of the board. Prior to Engooden, for nearly 20 years Tom was CEO of Curaspan, a discharge planning technology company that he co-founded in 1999 and sold in 2016. Before Curaspan, Tom held multiple business development roles at American Hearing Centers, Thermo Electron Corporation, and Specialty Chemicals Business, a division of Monsanto.

Topics: Interview / Q&A, Patient / Consumer, Provider, Trends
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