Practical Population Health

Transcription

1 Practical Population Health Key Steps to Identify, Stratify, and Manage Patients HFMA Managed Care Meeting January 29, 2015

2 Objectives Discuss the key capabilities for an effective care model for population health management Understand how to obtain data, use data to garner insights, and deploy resources to act on the information 2

3 Agenda Population Health Overview and Technology Requirements Obtaining Information Using Data Operationalizing Population Health Management 3

4 Valence Health Has Been Helping Provider Organizations Progress Toward Value-Based Care Since 1996 Technology-enabled services since 1996 National presence with 400 employees, 4 offices Serve IDNs, IPAs, PHOs, ACOs Select Clients Across the Value-Based Spectrum P4P PCMH Risk Strategy ( Pathfinder ) CLINICAL INTEGRATION SHARED SAVINGS Clinical Integration BUNDLED PAYMENT SHARED RISK Risk Arrangements CAPITATION FULL RISK HEALTH PLANS Health Plans Serve 35,000 physicians, 100+ hospitals Support 20 million patients 50 million member months in analytics and services Privately held 40% CAGR past 5 years IDN = Integrated Delivery Network, IPA = Independent Practice Association, PHO = Physician-Hospital Organization, ACO = Accountable Care Organization, CAGR = Compounded Annual Growth Rate, P4P = Pay for Performance, PCMH = Patient-Centered Medical Home 4

5 Providers and Payors Are Increasingly Addressing Market Pressures by Shifting to Value-Based Payments Hospital CEOs Expect 80% of Revenues to be Value-Based by % 90% 20% 80% 47% 70% 60% 78% 50% 40% 80% 30% 53% 20% 10% 22% 0% Valence Perspective Future Value-Based Models (2020) P4P, 10% Shared Savings, 10% Shared Risk, 30% Health Plan, 20% Full Risk, 30% P4P / Full Risk Bearing / ACO Fee-for-Service Payors are also announcing their shifts to value-based payments In early 2014, the state of Vermont pledged to make 90 percent of healthcare payments value-based within five years, as part of its application for a $45M state innovation grant 2 In July 2013, Minnesota-based UnitedHealth Group announced plans to more than double its value-based care contracts over the next five years, an expansion that is expected to reach $50Bn by ) The View from Healthcare s Front Lines: An Oliver Wyman CEO Survey, Oliver Wyman 2) State Already Moving Toward Value-Based Health Care Payments, Radar Wallack Says. Available at: vtdigger.org 3) UnitedHealth to Make $50bn Push to Quality-Based Contracts, Minneapolis/St. Paul Business Journal, July 11,

6 Population Health Management Provides Effective and Efficient Healthcare to a Defined Patient Population Population Health Definition A successful Population Health Management Program represents an efficient and effective health care delivery system for a population, and an approach to designing that optimal system of care Population Health Goals Support and partner with clinicians in optimally managing care for target populations Leverage care delivery system capabilities and avoid duplication Endorse PCMH and Patient Centered Medical Neighborhood (PCMN) principles Integrate medical and behavioral health components Design programs that are patient-centered Focus on Wellness and Prevention Develop a spectrum of services to meet value and risk-based contracting requirements as well as the care delivery needs of the population Ensure that program meets regulatory and accreditation requirements 6

7 Population Health Capability Requirements Vary by Provider; the Appropriate Strategy Must be Defined 1 Care Management The Population Health Management Components 2 Care Delivery System 3 Quality 4 Analytics and Clinical Information Systems A set of processes that address patient needs and promotes collaboration across the care continuum in the most efficient and effective way The patient care settings, capabilities, and resources required to successfully manage patient populations The collective set of evidence-based protocols, measures, and performance monitoring necessary to guide and improve care The technology, analytics, and reporting capabilities required to support care model execution Capabilities Required for Each Component Will Vary Based on a Number of Provider Characteristics*: Population segments served Degree of risk-sharing Available resource support Capability Requirements by Care Model Component Degree of delegation *Additional details on subsequent slides 7

8 In Order to Support the Population Health Program, an Analytics Platform Must Perform Four Main Functions # Functionality Required Provide information to physicians/care coordinators on patients medical history, risks, gaps in care, and physician quality Simply integrate with existing care delivery and management workflows Succinctly provide quality and cost information Integrate data across the entire provider network and continuum of care The following resources are necessary to meet functionality requirements: Technology Timely integration of quality and cost data Data governance Nimble environment Business intelligence capability Data Dashboards Alerts Data mining Easy distribution Standard reporting Advanced analytics Resources Skilled analysts Technical support Quality specialists Engaged providers 8

9 At the Core of Population Health is the Ability to Capture, Aggregate, and Act on Clinical Information Critical IT Capabilities for Population Health Management Data aggregation from disparate sources Including EMRs, hospital data, demographics, lab data, claims, etc. Across hundreds of provider locations Advanced analytics and ad-hoc querying High-risk patient identification Quality dashboard Reporting with only one-month lag time Multiple views of care delivery and care management across the network Patient-level, population-level Provider, administrative Evaluation of employed and affiliated provider quality performance CIN measures performance Primary care and specialist measures Clinical engine IT = Information Technology, EMR = Electronic Medical Record, FTC = Federal Trade Commission 9

10 There are Many Options for Technology Platforms which Vary by Cost, Functionality, and Ease of Integration Options for acquiring necessary data and technology capabilities 1 2 Acquire all affiliate physician practices Build technology platform from scratch 3 4 Purchase Health Information Exchange Require affiliates to adopt unified EMR 5 Purchase a population health analytics platform from a 3 rd party vendor COMPARE: What Information a Physician Obtains from Different Data Sources Category Sample Question Claims Data Shallow and late EMR Point Solution Incomplete Population Health Analytics Platform Balanced and useful High-risk clinical scenarios Who are my poorly controlled diabetics? Here are all patients with at least two diabetes claims with the same payor. Here are the diabetics you have seen. Who knows about the ones you haven t seen. Here are all the diabetics with a glucose >400 attributed to you. Pay for Quality (P4Q) How am I performing on my HEDIS measures? Here is how you did last year. We don t capture all your patients, and we can t see clinical events outside of your clinic. Here is a list of the diabetics assigned to you with open and upcoming care gaps. 10

11 Agenda Population Health Overview and Technology Requirements Obtaining Information Using Data Operationalizing Population Health Management 11

12 Analytic Requirements For Population Health Fall Into 3 Categories: Clinical, Network Management, and Financial Clinical Patient stratification Disease & Population management Population analytics Care management Gaps in care Episode and other groupers Patient engagement Provider / Network Management Provider efficiency Quality reporting Incentive model Provider scorecards Financial / Actuarial Trends and predictive modeling Risk adjustment Contract performance IBNR Pro-forma modeling 12

13 Clinical Analytic Requirements Identify Populations With High Opportunity and the Methods to Manage Them Clinical Analytic Requirements Capability Analytics Ideal State 1 Patient stratification Uniform risk adjustment for all payors 2 Disease and Population management Creation of custom registries, patient and population tracking and outreach 3 Care management Robust workflow to facilitate CM functions across continuum 4 Population analytics Detailed, integrated claims and clinical data to allow for complex analytics and the design of meaningful reports 5 Gaps in care Actionable information at the point of care 6 Episode and other groupers HCCs and other groupers uniformly applied to all payors 7 Patient engagement Proactive outreach alerts tool that is customizable 13

14 Once Data Is Obtained, the Population Should be Stratified to Allocate Resources in Most Impactful Way Practice Population Segments Care Delivery Complicated: Care Navigation Care Management Functions Case Management Disease Management High Risk: 2% Multi-specialty; Complicated Rx; Multi chronic conditions/meds; Palliation, EOL Intensive Monitoring Complex CM, with frequent contacts Intensive Moderate: Medium Medium / High Risk: 18% Chronic Diagnosis with complications, care gaps &/or poor compliance Periodic Tracking Routine CM, with periodic contacts Moderate Briefly Intense Medium/Low Low Risk: 80% Maintenance: Controlled Chronic Diagnosis; Acute illness Rx; Well care/ Prevention Blast Outreach & POS intervention Time-limited, Focused CM Broad outreach EOL = End of Life, CM =, POS = Point of Service, SDM =, SW = Social Worker, CHW = Community Health Worker 14

15 Technology Supported Insights Provide Guidance Into Areas of Clinical Gaps and Opportunities # of patients % Met overall % Met 14d visit % Met Card visit Track Performance by Physician Track Post-Discharge Follow-up CHF post discharge follow-up by physician Track Admissions and Readmissions 2 CHF admits in 2012, but no outpatient visits? Actively Track Patients with Overdue Care Track Admissions and Readmissions Jones, Martha Peters, Anne Tonks, Fred Day, Camile Schwartz, Saddie 7 CHF admits, 2 readmits <30d Globally or individually perform expedited outreach 15

16 Each Component of the Program Plays a Unique Role in a Patient s Journey Through the Healthcare System Referral Notification Referral Initial Member Contact Care Coordination / CM / DM IP / OP / Care Transitions Specialist Care OB Care Behavioral Health OB ER Outpatient Care Primary Care Medical Home PCMH Referral Health Risk Assessment - Medical - BH Urgent Care Plan of Care and Case Management Behavioral Health Diabetes Complex Case Management Inpatient Care - Clinical Evidence-Based Protocols - Pre-Admissions Protocols Transitions of Care (UM) After Hours Hotline Cultural Competence Outreach / Education / Health Promotion Social Services / Community PCP / Medical Home Partners Partners / Valence Partners / Hospital Providers / Care Transitions 16

17 Provider and Network Analytics Provide the Quality and Cost Transparency to Affect Change Provider / Network Analytic Requirements Capability Analytics Ideal State 9 Provider efficiency Detailed cost and utilization reporting at physician level, including peer and network comparisons 10 Quality reporting Detailed quality metric reporting at physician level, including peer and network comparisons 11 Incentive Model Consistent and transparent incentive model in place so physicians understand requirements 12 Provider scorecards Scorecards which show timely quality and cost metrics, and are produced on a consistent basis and easy to understand 17

18 Quality Reporting Provides Network Performance Comparisons for Selected Quality Measures Desired Attributes for Quality Reporting Includes meaningful indicators of quality Attributes patients to physicians in a way that I trust Enables users to understand & improve the quality of care provided to patients Sufficiently incorporates benchmarks & targets Provides intuitive and actionable reports & dashboards Allows users to drill down easily & sufficiently Compares performances across providers/practices in a valid manner Will allow my organization to display its value-based business case (i.e. organizational performance) Quality Measures Module Physician Drill Down Capability 18

19 The Physician Incentive Structure Should Be Adapted to Support the Goals of the Population Health Program To execute a successful Care Model, the physician incentives / compensation model should be aligned with network goals Why is it important? Reinforces a value-based mindset Empowers physicians/network with the tools to objectively measure performance and target areas for improvement Supports the creation and maintenance of a high performing physician network Incentive Program Key Components A balance of quality and utilization measures Potential incentives represent a significant portion of physician compensation Metrics that are attractive to payors and consistent with contracts Metrics meaningfully measure quality of care and cost management Achievable performance targets Defined metrics for each physician An effectively executed monitoring/remediation plan The ability to collect/distribute data in a timely fashion 19

20 Incentive Payments to Physicians Are Typically Based on Both Network and Individual Performance Example of Physician Incentive Payment Model Network Performance 50% Efficiency 50% Quality Individual Performance 70% Group 30% Individual Score Opportunity (based on allowable billings) x = Incentive Payment 50% Efficiency 50% Quality Based on actual experience of Valence Health client 20

21 The Scoring and Payout Methodology of Incentive Program Metrics Can Be Tailored To Each Metric Weighted Performance Measures Example Performance Thresholds 100% % compliant = 100% payout 10% 10% 75% QA Quality Metrics 51-75% compliant 60% = 75% payout 20% Efficiency Metrics 50% 26-50% compliant Patient Experience = 50% payout Physician Engagement 25% <=25% compliant = no payout Performance threshold quartiles could be determined dynamically based on metric result distributions OR predetermined based on desired performance levels/benchmarks 21

22 An Ideal IT Solution Will Meet the Needs of an Entity Operating Under a Full Risk Arrangement (3 / 3) Financial / Actuarial Analytic Requirements Capability Analytics Ideal State 13 Trends / predictive modeling Detailed claims level data will allow trend analysis and predictive modeling capability 14 Risk adjustment Uniform risk adjustment for across entire at-risk population (may include multiple payors) 15 Contract performance Produce own reports to assess recent performance 16 IBNR Estimation of pending claims that have not yet been received 17 Pro forma modeling Detailed claim level data for robust modeling 22

23 A High-Level Dashboard Provides Insights into Trends Related to the Cost and Quality of Care Manage value-based contracts Attribute / allocate costs in a meaningful way Understand and optimize cost-effectiveness of care provided to patients Compare cost over time vs. cohorts vs. benchmarks Analyze medical costs and trends Compare cost over time vs. cohorts vs. benchmarks Understand and optimize the utilization of healthcare services within the network Avoid unnecessary cost and utilization (i.e. duplicative tests, services, etc.) Track medical expense across major expense categories Catastrophic claims Medical claims distribution Profile physician performance on cost and utilization Profile practice performance on cost and utilization 23

24 Agenda Population Health Overview and Technology Requirements Obtaining Information Using Data Operationalizing Population Health Management 24

25 Successful Population Health Programs Define a Strategy that Address the Key Components of the Program ASSESS ADDRESS PRESENT Month 1 Month 2 Month 3 Risk strategy Payor arrangements Infrastructure Investment resources Network description and capacity Care management programs Clinical information systems Analytical tools Project overview and timeline Care management components and definitions Overview of requirements by risk level Impact of target populations Facilitate discussion on: Network configuration and barriers Physician leadership Organizational barriers Access and capacity Staff capabilities Align risk level requirements with current capabilities Propose integrated care delivery models Identify staffing resources and requirements Define quality metrics and monitoring Detailed requirements by risk level High level gaps Recommended quality metrics Performance improvement process Identify preferred continuum management models Recommend staffing plan Discuss physician engagement strategies Prioritized recommendations to address gaps Projected costs Implementation plan Identify unanswered questions/next steps 25

26 Population Health Management Begins by Assessing Population Requirements against Current Capabilities Degree of Risk Payor Contracting Snapshot Current Network Capacity Population Segments Served Provider network Facilities and partnerships Patient access High Risk: X% Medium Medium / High Risk: Y% Briefly Intense Medium/Low Low Risk: Z% Establishing a sound fact-base at the start of our work will help to inform the appropriate care model design and gap analysis 26

27 The Capabilities Required for Population Health Management Differ Based on Level of Risk-Sharing Legal and Regulatory FEE FOR SERVICE P4P SHARED SAVINGS BUNDLED PAYMENTS SHARED RISK Financial Opportunity & Incentive Alignment CAPITATION FULL RISK PROVIDER- SPONSORED PLAN Marketing and Sales Claims Administration Analytics Financial and Risk Arrangement Care Management Provider Network 27

28 Funding Sources for the Population Health Program Will Vary by Activity and Resource Type Program Component Owner Funding Delivery System Care Coordination Activities Care Navigation PCMH / PCMN Activities Hospital UR / CM / SW Practice / ACO Practice Facility Included in reimbursement and/or may require additional contribution, or incentives/p4p to support these activities Included in reimbursement or incentives, and expected to continue/intensify Program Component Owner Funding Health Plan Management Activities (ACO to supplement selectively; Function may transition to ACO if full risk / delegated) Utilization Management Case Management Disease Management Health Plan ACO, Health Plan ACO, with some activities deployed locally within the ACO based on specific populations Funding through Health Plan PMPM for delegated activities 28

29 Set Specific Program Goals Based on Existing and Desired Contracts Care Transitions Program Goals Focus on reducing unnecessary readmissions Bridge gaps between care settings (e.g., hospitals, skilled nursing facilities, (SNF), home care) Work with existing hospital/snf case managers, social workers, and support staff Follow patients for at least 30 days post-acute event (e.g., contact patient within hours post-discharge and as needed thereafter, schedule follow-up appointments, perform medication reconciliation) Ensure seamless handoffs to ambulatory case managers and coordinate with primary care physician (PCP) 29

30 Assess Current Staff Capabilities and Functions Before Committing to Hiring Additional FTEs Resource UM Tech Case Manager Social Worker Community Health Worker Care Navigator Medical Director Pharmacy Care Management Director Quality Director and Staff Analyst Guidelines for staffing requirements: 1 Different aspects of population health (ex care delivery operations vs care coordination) have different measures and benchmarks for success 2 Estimate staffing needs based on number of attributed lives, with adjustments by payor type (ex Medicare, commercial, Medicaid) 3 Evaluate whether current staffing is providing efficient, effective practice operations before supplementing staff: Benchmarks are met: Basic practice operations match industry standard staffing models and meet industry performance benchmarks (MGMA) Key practice functionalities are in place: 24/7 telephone coverage with physician availability, readily available phone advice/medication refills in practices, max pack office visits, etc. 30

31 There are Different Levels of Population Health Management, Adoption can be Gradual Crawl Walk Run Immediate Modify tactics as program matures Next In parallel locally, and later Program Focus Basic blocking and tackling : Leakage Access to data; utilize what s readily available CM/DM/Populations: High cost High frequency High risk Enhanced capabilities: PCMH, Navigators/Coach Care Continuum/Transitions/ Practice Pattern Changes Adopt care guidelines, measure and share data Quality, utilization & financial reporting; Care Navigation: use tools Performance Improvement Network/Incentive Focus Participation Process Process Outcomes Outcomes VALUE Outreach/Patient Focus Educate Engage Empower UM = Utilization Management, CM = Care Management, DM = Disease Management 31

32 Thank You For additional questions and comments, please contact Lori Fox Ward at vquest Medical Cost & Utilization Risk Adjustment Vision Clinical Integration Quality Measures Population Health for Multi-TIN Settings Registries Population Health Management Solutions Health Plan Services Claims Processing Premium Billing Provider Portal Member Portal Care Manager Case Management Care Coordination Patient Outreach 32