Defining the Value of GIM in Academic Health Systems Leadership Perspectives

Transcription

1 Defining the Value of GIM in Academic Health Systems Leadership Perspectives ACLGIM: Training & Leadership Institute April 24, 2013 Andrea Sikon, M.D., F.A.C.P. Chair, Department of Internal Medicine and Geriatrics Medicine Institute

2 Objectives The Changing Healthcare Landscape - Drivers of volume to value - Evolving care delivery models Academic medical centers Where GIM fits in - Our Cleveland Clinic (CC) story Threats and opportunities for Primary Care

3 Costlier Care is Often Worse Care 7

4 A Strategy for Health Care Reform Toward a Value-Based System Value = Quality/Cost Michael Porter NEJM 2009; 361:

5 Value of Primary Care: Existing evidence hospitalization rates Lower costs health outcomes - cancer, cvd mortality - Nation premature births, deaths from treatable conditions, and post neonatal mortality. specialists = per capita Medicare spending Vast majority of Americans prefer a sustained relationship with a PCP dysfunctional_payment.pdf Accessed 4/20/13.

6 Today Care is Fragmented, Variable and Discontinuous Community-Based Care Acute Care Hospital Wellness / Fitness Center Surgery Center Urgent Care IRF Retail Pharmacy Home SNF Outpatient Rehab Physician Clinics Diagnostic / Imaging Center NEJM 2009; 361: Recovery and Rehab

7 The New World Volume-Based Value-Based Payment Fee-for-Service Outcome Based Incentives Volume Value Focus Acute Episodes Populations Role of the Provider Single Episodes Care Continuum Information Retrospective Predictive

8 Care Transformation is Critical Transform the clinical operations Assemble the right care team Reward added value with sustainable payment models Support with the correct Analytics 8 17

9 Step 1: Transforming Operations Patient Engagement Safety and Quality Treatment of Patient as a Whole Comprehensive and Coordinated Care Enhanced Access Physician Directed Practice Payment for Added Value There s Benefits of Implementing No Place the PC PCMH: Like A Review a Medical of Cost & Quality Results Home

10 Step 2: Assembling the Right Team: Where are AMCs & what is the role of GIM?

11 NEJM 2011:364e11 NEJM 2011:e12 (1-3) + Existing relationships w/ multispec groups Market leaders Strong network w/ community hospitals/physicians Advanced IT integration Clinical quality tracking ACOs and AMCs - Subspeciality dominated Highest cost Culture- hierarchal & silos Must strengthen ties w/ community practices Increase agility Reward system

12 The Right Team: What is the role of Primary Care? ACP IOM.edu/bestcare

13 Step 3: Reward added Value with Sustainable Payment Models Evaluate a variety of payment options and pursue a multipronged approach with the payers Additional PMPM Global payment Enhanced fee-forservice Pay-forperformance / Gainsharing Recognizes additional billing codes for services Recognizes additional care provided for each patient Covers all patient primary care need for a set period of time Rewards high quality / low cost care with bonuses 20

14 Step 4: Support with Correct Analytics/Health Info. Technology Accuracy, usability, timeliness

15 Value is the Centerpiece of Cleveland Clinic Strategy

16 Cleveland Clinic Health System 2,800 salaried physicians 33,000 employees 120 medical specialties & subspecialties Locations: - Main campus - 8 community hospitals - 18 Family Health Centers in NE Ohio - Florida, Las Vegas, Canada, & Abu Dhabi 4 million visits in 2010 Patients from every state & > 100 countries

17 CC Mission & Culture Better care of the sick, investigation into their problems and the further education of those who serve -- CC Founders Striving to be the world s leader in patient experience, clinical outcomes, research & education Quality, innovation, teamwork, service, integrity, compassion Patient s First Transparency

18 Unique factors at CC Physician governance Serving Leader foundation Group practice- salaried Staff model Robust professional development A Learning Health Care System - IOM 1 - Continuous Improvement support 1-Iom.edu/bestcare

19 Cleveland Clinic Integrated Care Model: A Value-Based Patient-Centered Model of Care Personalized Patient-focused Integrated Continuous Transcends time, physical location Right care, right place, right time Primary care and Specialty Care 19

20 HCR at CC: Making it happen Executive Team (ET) buy in Operationalizing the plan - Institutional Developing the infrastructure - Local Medicine Institute= Primary Care

21 Creating ET buy in: The Primary Care value pivot Key institutional leaders are PCPs & national leaders - MI, Community Hospitals Presidents, Quality, IT, Business Intelligence & Medical Operations Advisory Board input Government relations department Employee Health Plan- Mini ACO 80K lives 3 rd party payer interest

22 Institutional: Developing infrastructure - Institute reorganization Full CCHS integration- One CC Community Phys. Partnership- Employed model EHR full integration & Optimization CMIO Supply chain consolidation Centers of excellence - Quality Alliance - Data and analytical tool development - Chief strategy officer position created

23 Operationalizing the Plan: Local Expanded Primary Care at FHCs Longstanding quality metrics - -> Transparency mid 2000s Medicine Institute (MI) chair leading institutional Value Based Care effort MI planning team with local site leaders

24 The Cleveland Clinic Who we are Medicine Institute Five clinical departments - Family Medicine - Community Internal Medicine - Internal Medicine and Geriatrics - Infectious Disease - Hospital Medicine 329 Physicians: 214 Primary Care (155.4 FTE) Physicians 29 Sites, 40 practices for Primary Care 550,000 visits 10 sites received NCQA level 3 recognition in 2010

25 Cleveland Clinic Value Based Care VBC Population Management Guidance Team Chairman David Longworth, MD Care Coordinator Workflow Evaluation Team Strongsville Site Team Main campus Site Team Clinical Pharmacy Workflow Independence Site Team Metrics: Access, quality, patient experience, cost, ER visits, hospital admissions, hospital-re-admissions, provider satisfaction 25

26 Medicine Institute Population Management Projects in 2012 Initial Projects: 60,000 lives, 20% of providers TeamCare (Strongsville FHC) MD-RN model (Main Campus G10) MD-APN-MA model (Independence FHC) Embedded chronic disease managers Embedded pharmacy support of different intensities PCMH tenants: Top of license, pre-visit planning IM longitudinal resident clinic re-design 26

27 Early results Caregivers highly engaged Many positive anecdotals from patients No post implementation data yet on cost or utilization from payers (-EHP) Quality metrics strong Hospital re-admissions fell 15% in third quarter 2012 at pilot sites (7.7%-27.7%) TeamCare has enabled providers to increase daily visits from 20 to

28 Ongoing work Extend practice redesign to all PC sites Next steps: - Institutional level: Institutional Care Paths Ever-evolving data/analytic tool - Local level: phased approach Behavioral health Community services PCMH neighborhoods (sub-specialities)

29 Prepping for success Setting the culture locally - Kick-off event - Change management training for all Űber communication! Maximally empower front line Metrics & Outcomes sharing: - Short term and long term metrics - Add non-traditional methods

30 Lessons being learned Common thread= Relationships Rapid process cycle continuous improvement Lots of recognition (Need for breaks!)

31 Threats for Primary Care Rapidness of change Developing Infrastructure - Failure to fully integrate - Getting things to front line users - Data difficulties- too little and too much Information overload - Numerous metrics - Rapidly deepening clinical knowledge base - New skills - Process adaptation

32 Threats for Primary Care How to fund changes now? - Need to operationalize new models before full reimbursement transition Timing/Failure of true funding transition

33 Threats for Primary Care Government oversight - Much undefined in ACA - Multiple agencies/variable definitions - State variation Patient activation - Understanding implications of value over volume shift - Skin in the game - Tools/resources

34 Opportunities for Primary Care Team skills- Interdisciplinary training & leadership skills Redesign operations to optimize Relationships: - Top of license preceded by trust Community integration Enhanced predictive analytical capabilities

35 Opportunities for Primary Care Rethink training - AAMC s Healthcare Innovation Zones (HIZs) JAMA. 2010;303(9): doi: /jama Expand PCP training skillset: Teamwork- interdisciplinary Leadership Quality Continuous improvement Health care policy

36 Imperatives for transition Innovation needed - New training, technology, systems changes Culture shifts True teamwork across disciplines & beyond, pool resources No one sized fits all approach Manage expectations Continued sharing of best practices

37 Future research focuses Comparative effectiveness Optimal educational techniques (exponential skills, interdisciplinary) Predictive modeling Decision support Patient activation Practice redesign Transitions of care Optimal determinants of quality

38 Opportunities for SGIM/ACLGIM Continued sharing of best practices Continued skill development: Teamwork/interdisciplinary, leadership, quality, continuous improvement, change management, health care policy Extension to trainees Continued Health Policy advocacy

39 GIM is well poised Diverse interests and skills Essential foundation of care= PCMH Already relationship-centered We are educators and researchers We can be the leaders of reform and implementation

40 Resources for GIM & HCR The Advisory Board: Patient-Centered Primary Care Collaborative (PCPCC) Institute of Medicine: The Learning Healthcare System spx American College of Physicians: - d/assets/i1-summary.pdf

41 All our dreams can come true, if we have the courage to pursue them. Walt Disney

42 Success is not final, failure is not final: it is the courage to continue that counts. Winston Churchill

43 Thank you!

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45 Questions and Discussion

46 Back-Up Slides

47 3 Elements of Successful Population Management Primary care-led clinical workforce Elevate PCP to CEO of care team Mobilize community workforce to extend care team reach Information-powered clinical decision-making Use robust patient data sets to support proactive, comprehensive care Operate within an integrated data network Position a leader to merge data analytics with clinical care Patient engagement and community integration Map services to population need Overcome nonclinical barriers to maximize health outcomes Integrate patient s values into the care plan Use community stakeholders to connect patients with high-value resources

48 Remaining questions

49 Charity care at Cleveland Clinic - Persons with incomes up to 400 % of Federal Poverty Level w/in 150 miles - In 2009, $120 million 20% increase for 2010.

50 Institutes at Cleveland Clinic- Clinical Anesthesiology Cancer (Taussig) Children's Hospital and Pediatrics Dermatology & Plastic Surgery Digestive Disease Emergency Services Endocrinology & Metabolism Head & Neck Heart & Vascular Imaging Medicine Neurological Ob/Gyn & Women's Health Ophthalmology Orthopaedics & Rheumatologic Pathology & Lab Medicine Respiratory Urology & Kidneys Wellness

51 Institutes at Cleveland Clinic- Non-Clinical Arts & Medicine Education Nursing Philanthropy Institute Quality & Patient Safety Regional Operations Research (Lerner)

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