Navvis: The Pursuit of Integrated Physician-Driven, Patient-Centric Population Health
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Navvis: The Pursuit of Integrated Physician-Driven, Patient-Centric Population Health

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Chuck Eberl, Chief Strategy Officer, NavvisChuck Eberl, Chief Strategy Officer, Navvis There are many companies trying to solve the challenges that exist in population health and value-based care. One company that stands out is Navvis—a company that is taking an entirely new and different approach. Instead of developing single point programs and services, Navvis has developed a solution that focuses on solving the holistic and systemic issues that health plans, health systems, and physician organizations face. “The real problem limiting the success of many population health initiatives is that the healthcare system is disconnected and fragmented,” said Chuck Eberl, Chief Strategy Officer at Navvis. “Success demands a broad and strategic approach that unifies the system.” Navvis’ goal is to work with local partners to create an ecosystem that never stops caring for people—one that is proactive instead of reactive, integrated instead of siloed, and one that is personalized, holistic, and led by the physician.

Healthcare is Local

Navvis solves the challenges of population health by addressing the unique characteristics within each specific market and geography. Working with a leading healthcare company in-market (such as a health plan, health system, or physician organization), Navvis develops a business plan and operating model that will fund the development of a connected care ecosystem and allow all of the key stakeholders in the market to contribute, participate, and achieve success. This geographic market approach creates ‘models of population density’ which drive alignment and engagement with physicians. Combined with an approach that is all payer, physicians can deliver the same high-quality care to everyone in their panel. “Our all payer, all provider, all patient approach makes it simpler and easier for physicians, and we empower them to deliver on what matters most— great health and great healthcare,” said Eberl. “The healthcare leaders we work with want to address the entire population and people from all walks of life who live and work in the communities they serve. They want a system that supports all payers, payment models, and lines of business, connects the full continuum of care and activates all providers, caregivers, and family members,” continued Eberl.

A New Framework: The Six Pillars of Population Health

Navvis sees pockets of population health initiatives across many organizations and sees a significant opportunity to solve the systemic issues and scale these efforts across populations and markets.


The real problem limiting the success of many population health initiatives is that the healthcare system is disconnected and fragmented. Success demands a broad and strategic approach that unifies the system


The company’s solution framework is called the ‘Six Pillars of Population Health’ and is deployed into the connected care ecosystem developed in local markets. These pillars are the fundamental building blocks that healthcare organizations need to develop, operate, and deliver next-generation population health.

The pillars include Processes, People, Networks, Governance, Payment Models, and Technology. “Technology is critical to scale care to millions of people, and often that is the place many organizations start their journey,” said Eberl. “For Navvis, technology is intentionally the last part of our Six Pillar framework. We need to ensure that things like processes, people, and payment models are all properly aligned before the technology is deployed.”

Technology that Supports People and Process

Along with care coordination, high-performing and aligned provider networks, and value-based care models, Navvis delivers a comprehensive technology platform called Coreo. Coreo integrates data analytics, care coordination, cross-continuum patient management (acute, post-acute, and home), and in-home caregiver services and tools. The platform serves as the foundation for the deployment of Navvis’ person-centered, physician-led, and team-based care model. Coreo includes:
Cross-continuum visualization of a person’s ‘life map’ (Navvis’ next-generation approach to care plans)
A provider-friendly model that provides critical data, dashboards, and tools for providers and their teams to better support patients
Activation of caregivers and social service organizations
Team-based care coordination, including physicians, all care team members (clinical and non-clinical), community resources, and family members
Data-powered clinical decision making
Seamless data and workflow integration

The Coreo platform is person-centric, placing every person at the center of his or her care. Coreo works to coordinate an interdisciplinary team around each person and his or her unique needs. The platform enables Navvis and their client partners to capture what matters most to every person and to define and support a life map (next-generation care plan) that encompasses a longitudinal view of each person and the direct involvement of providers, community resources, and family members.

Case Study: The First Statewide Value-Based Primary Care Model in the U.S.

Navvis’ approach and their solution have helped healthcare organizations across the country create positive population health outcomes. One example is their work with Hawaii Medical Service Association (HMSA), the Blue Cross Blue Shield health plan in Hawaii, to develop and deploy a value-based payment model to primary care physicians (PCPs). In 2014 HMSA decided to accelerate a transition to value-based care. Their first step was to roll out a pioneering payment program for their PCPs. The payment transformation program swaps the traditional fee-for-service model with a single monthly payment for every HMSA patient in a PCP’s practice. In the new model, payments are adjusted to reflect the needs of patients while compensating physicians when they engage patients with preventive measures.

Further, the PCPs are rewarded for quality, efficiency, cost-effectiveness, and innovation. Together Navvis and HMSA worked to include all of the physicians and other community stakeholders. Through value-based payment models, physician governance, practice transformation, and physician engagement, Navvis and HMSA empowered physicians and other care providers with tools and resources so that the physicians can do their best work and deliver exceptional care to patients.

The results of the pilot program published in the Journal of the American Medical Association (JAMA) show a 2.3 percentage point increase in the quality of patient care with no increase in healthcare costs. Additionally, physicians report improvements in preventive care with higher percentages of patients receiving colorectal cancer screenings, mammograms, immunizations, and diabetic eye exams. The work in Hawaii is an industry-leading example of value-based payment models and is serving as a national example for payment transformation.

The Journey Ahead

Having established itself as an innovator in population health, Navvis aims to create a tipping point by improving the health of over 20 million people. To achieve this goal, the company is working with market leaders including HSMA, the Blue Cross and Blue Shield health plan in Hawaii; Florida Medical Clinic (FMC), an industry leader in value-based healthcare; Horizon, New Jersey’s oldest and largest health insurer; and SSM Health, a large health system serving communities across the Midwest.

Navvis recognizes that ultimately, the U.S. healthcare
system has to pivot from a system that currently asks
people ‘What’s the matter with you?’ to one that asks ‘What
matters to you?’ When this becomes the core question,
solutions no longer stop and end with treatment, and the
system dramatically changes to one that never stops caring
for people, supporting them throughout their lives.