System Options to Achieve the Triple Aim

Transcription

1 D30/E30 This presenter has nothing to disclose System Options to Achieve the Triple Aim David M. Williams, MD, CPE Medical Director UnityPoint Health Partners December 10, 2014 Objectives Evaluate their current strategies and performance against the multiple models presented Develop a strategy that works best for their organization over the next two to five years 2 1

2 Iowa Health System UnityPoint Health

3 It s not about being bigger. It s about being better. 5-Year Vision: Achieve national brand recognition as a care coordination leader Achieve regional recognition as the provider of choice delivering top tier quality, patient experience and access Position UnityPoint Health to effectively manage population health in a value-based reimbursement environment 5 Key Premise In three years, we will be working in a mixed environment of fee-forservice and value-based payment. We assume the split between the two will be 40% fee-for-service and 60% value based payment. 6 3

4 HOME HEALTH SKILLED NURSING FACILITIES LONG TERM CARE ORGANIZED SYSTEM OF CARE (OSC) CROSS-CONTINUUM PHYSICIAN LEADERS DRIVE CARE TRANSFORMATION LOCALLY PUBLIC HEALTH MENTAL HEALTH HOSPITAL FQHC CLINICS HOSPICE 7 Regional OSC Leadership Committee Quality & Clinical Integration Finance & Network Development Committee Committee Physicians and Providers Quality & Clinical Integration Council UnityPoint Health Partners Finance & Network Development Council Board of Managers 8 4

5 9 4 Population Health Realities Risk Factors, not disease, are crucial for identifying tomorrow s high-cost patients. Collaboration across the continuum (Network) is crucial or patients will find themselves in cul-desacs. Temptation is to Boil the Ocean, both as a system and/or within regions. A focused framework is necessary. Risk adjustment of your managed population is a reality; enhanced ambulatory documentation related to claims submission becomes critical 10 5

6 End Zone Hospital Clinic Insurance Top 10% Patient Satisfaction Triple Aim Top 10% Composite Quality 5 Star Performance Medicare Advantage Top 10% $ PMPM by Contracted Population Regional: STAR WARS (Premiums - Claims) + (FFS Operating Expense) = System Profit What is the Playbook? 11 Playbook: Care Model Roadmap Risk Stratification: Risk Coding, Claims, EHR, HRA Data High Risk Patients Rising Risk Patients Low Risk Patients Outlier / End of Life High Risk Patient Initiative Case Management Hospice 2 nd Gen Patient Centered Medical Home Super Visit 1:1 RN Care Manager MTM Behavioral Tele Outreach Attachment & Retention Registries/Gaps Care Coordinator MTM Behavioral Tele Outreach Connect to PCP Virtual Tools Prevention Palliative Next Gen Hospitalist Program Connection to Community Resources Common Care Plan Standard Transition in Care Call Center Access & Access Standardized Clinical Pathways Transition to Care Model Roadmap: without FTE additions 6

7 280+ clinics 1,000+ providers One brand focused on patient-centered, coordinated care 13 Home Hospice Ambulatory Palliative Care The Point of Unity is You! Advanced 24 Hour Call Center? Medication Therapy Management Integrated Home Care Care Navigators? Clinical Technologies & Virtual Health? Leading Edge Home Care 14 7

8 The Point of Unity is You! Emergency Physicians Care Navigators Medication therapy management Palliative care Hospice Integrated home care Community resources Hospital at Home Hospitalists System Options to Achieve the Triple Aim Jeff Grossman, MD President and CEO University of Wisconsin Medical Foundation 8

9 The Science of Health Care Delivery In my view, the rocket science in health and health care is how we deliver it. -- Dr. Jim Yong Kim, President, Dartmouth College UW Health Delivery System Redesign Work Plan Work to be Done Longitudinal Care Episodic Care Primary Care Specialty Care Hospital Care Better Care Individuals Better Health Population Health Lower Costs Through Improvement Improve Access Palliative Care Preventive Care Transitions In Care Hospital Acquired Conditions Population Health Management Patient Centered Medical Home / Primary Care Redesign / Care Coordination Quality and Process Improvement Bundled Care Patient and Family Centered Care Tele health Foundations of Change Culture that demands standard work, team based care and sets clear expectations Evidence Based Medicine Value based Payment / Compensation / Business Models Robust Measurement and Reporting System ACO Legal Structure -UW Health ACO Initial Priorities 9

10 Engaging Physicians in Quality Work at UW Health through MOC ABMS Board Certification Administered by the 24 Member Boards, the ABMS Maintenance of Certification (ABMS MOC ) program is a four-part process Part I. Licensure and Professional Standing (maintain your medical license) Part II. Lifelong Learning and Self-Assessment (get enough CME) Part III. Cognitive Expertise (pass your board exam) Part IV. Practice Performance Assessment: Demonstrate use of best evidence and practices compared to peers and national benchmarks (do quality improvement work using performance data) 10

11 UW Health MOC Portfolio Program: An opportunity to align demands External Demands (regulation, insurers) UW Health Goals Clinic/Unit Priorities MOC Achieving Efficiency through the UW Health MOC Portfolio Program In 2013, UW Health was approved as an MOC Portfolio Sponsor UW Health has the authority to approve internal QI efforts for MOC Part IV from participating boards UW Health MOC Portfolio Program is administered by UW SMPH Office of Continuing Professional Development and UW Health Quality, Safety and Innovation The MOC Portfolio Program provides a stream lined process for physicians to fulfill Part IV credit for their individual Boards by participating in well designed QI efforts at UW Health 11

12 Benefits to being an MOC Portfolio sponsor organization: Physicians can work together on improving care for a population of patients (within and between clinical departments) UW Health can learn about innovations in care when physicians share their improvement projects Helps physicians at UW Health document meeting Part IV requirements through their work on QI projects carried out by UW Health Help align the QI efforts of UW Health physicians with priorities for their clinical settings, departments, and UW Health Dr. Smith needs to complete MOC Part IV. Her Board participates in the Portfolio Project. ENROLL in a UW Health Improvement Initiative that has already been approved for MOC Part IV credit. APPLY to the MOC Program for approval for your own improvement project. 12

13 UW Health MOC Portfolio Program Website Web Address: moc.wisc.edu Learn about: MOC QI Process MOC Program Structure MOC Documentation Completed Projects THANK YOU! Publishing Quality Improvement Work The Website 13

14 Embracing Primary Care at UW Health URGENCY FOR CHANGE Loss of GIM physicians to hospitalist roles and others to competitor hospital PCP compensation drifting below market Difficulty recruiting national shortages 2 years of GIM residents with no interest in primary care Poor access Changing work of primary care expanding volume of non face-to-face work not recognized with RVU Health Care Reform UW Health ACO Perception of Hamster Wheel with productivity drivers 14

15 ORGANIZATIONAL RESPONSE UW Health Primary Care Redesign initiative New model of care delivery based on patient centered, team-based care focused on population management and health Emphasis on value Work toward PCMH recognition STANDARDIZED JOB EXPECTATIONS - COMPACT Population management Clinical FTE defined/standardized Face to face and non face to face hours Citizenship Care team leadership Quality improvement 15

16 PLAN PRINCIPLES Support evolution of the redesign of the primary care delivery system model One plan for all primary care physicians Focus on clinical compensation Support physician led, team based care Base on size of the population cared for (weighted panels) Allow structured customization at the specialty level to promote innovation and recognize unique differences Retain market sensitivity move to leading edge Recognize all work done on behalf of a patient population Provide stability /predictability to compensation lean toward salary type system Incorporate value metrics (focus on areas MDs can and should control) o Quality of service o Quality of care o Health of population o Costs of care Understandable, equitable, transparent BASIC PLAN Available compensation dollars are based on size of individual physician and site physician team panels Market basis defined by weighted external specialty specific median compensation Median market compensation linked to 1800 weighted active panel Site pool of dollars allocated based on work done on behalf of all patients of the site Incentives/cost sharing for incorporation of APP on care teams Dollars at risk for meeting standard job expectations Incentive pool funded by organization for outcomes of panel management/population health (Quality) 16

17 COMPONENT DEFINITIONS Benchmark Median Specialty Compensation Annually derived from weighted average of three national surveys recognized by UWMF (AMGA, MGMA, McGladrey) Target Weighted Panel Size Derived from review of limited market information and historical activity of our patients Panel Weighting Based on age, sex, payer and three yr historical activity at PCP sites derived from data on 360,000 patients reported monthly to all physicians adjusted every 6 months for compensation calculation FAMILY MEDICINE Individual MD Site Pool Dr. A $210,024 Dr. A Benchmark Median Comp ($210,024) $175,020 Dr. B $233,360 Dr. C Dr. B Dr. C $618,404 Site Pools Allocation Panel $309,202 50% 50% $309,202 Work Individual MD Allocation 1800 x $309, Dr. A 4600 x $309, Dr. A 1500 x $309, Dr. B 3500 x $309, Dr. B 2000 x $309, Dr. C 4900 x $309, Dr. C MD Comp $105,012 + $108,410 $214,422 Dr. A $87,510 + $83,237 $170,751 Dr. B $116,680 + $116,545 $233,225 Dr. C 17

18 AT RISK 5% withhold on panel based compensation Annual performance review linked to achievement of specific metrics linked to standard job expectations (MD compact) Expectation that all can earn the with hold at end of year Availability of compensation pool guaranteed by organization MODIFICATIONS Utilized to deal with special or unique situations which cannot be adequately recognized in the core plan All are subject to ongoing review and modification as plan evolves and environment changes and do not require vote to change the core plan Examples include physicians who perform unique procedures, FM participation in OB, coverage of hospital care for newborns by pediatricians, expense of APP 18

19 APP Estimate that the presence of a 1.0 FTE APP allows a team to care for an additional 900 patients Site with APP charged with 50% of salary and benefits of APP Phased in expense charge over 3 years when APP is added to a site to allow for practice growth Requires about patients added to panel to cover the cost of APP Incents teams to effectively incorporate APP on teams optimize utilization of physicians reduce long-term costs of excess physician recruitment QUALITY 5% (additional) pool of base compensation set aside by organization Linked to quality (service and care), health outcomes, costs of care Specific metrics defined by Quality Council and Operations Council Revised annually 19

20 OUTCOMES Increased physician satisfaction Panel size/fte MD increased Increased use of APP Three MD departures replaced with APP Quality metrics improved Patient satisfaction increased PATIENT SATISFACTION ACCESS 20

21 WCHQ QUALITY METRICS MD SATISFACTION Question 2011 All 2013 All % Satisfied or Very Satisfied DFM DFM GIM GIM 2011 GPAM 2013 GPAM Comp Plan Structure 31% 60.6% 24% 59% 65% 83% 22% 76.4% Annual Salary Received 36% 72.3% 28% 75.4% 64% 82.4% 34% 50.1% Level of Understanding of Plan NA 59% NA 56.7% NA 76.4% NA 50.1% 21

22 FUTURE Increase % allocated to value/quality Adopt site care team modifications to work allocation Define cost (delivery system and care) measures for value metrics Ongoing refinements to panel weighting Education/communication Specialty compensation changes System Options to Achieve the Triple Aim Jeff Thompson, MD Chief Executive Officer 22

23 Today We Are An Integrated Delivery System 65 Clinic locations; Primary and Specialty Care 5 Hospitals including behavioral health Medical Foundation 6,475 total employees 505 doctors Population Health Experience of Care Per Capita Cost 23

24 Start With The People 24

25 Medical Staff Compact Gundersen Health System s Responsibilities Achieve Excellence Recruit and retain outstanding physicians and staff Support career development and enhance professional satisfaction Acknowledge and reward superior performance that enhances patient care and improves Gundersen Health Systems Create opportunities to participate in quality improvement, research, and improvements in community health Communication Communicate information regarding organizational priorities, business decisions, and strategic plans Provide opportunities for constructive dialogue, clarity of goals, and regular evaluation Educate Support and facilitate teaching and learning opportunities Provide the tools necessary to continually improve medical practice Reward Provide competitive compensation consistent with market values and organizational goals of quality, service, and efficiency Maintain clear organizational responsibility and integrity to those it serves Change Manage the inevitable rapid changes in healthcare so that staff have an opportunity for participation, for clarity of goals, and continuous modification of the process as well as the outcomes Medical Staff Compact Medical Staff Responsibilities Focus on Superior Patient Care Practice evidence based, high quality medicine Encourage increased patient understanding, involvement in care, and treatment decisions Achieve and maintain optimal patient access Insist on departmental focus on superior patient service Work in collaboration with other physicians, support staff and management across the system in both service and patient care improvements Demonstrate the highest levels of integrity and professional conduct Participate in or support education and research Treat All People With Respect Listen and communicate both clinical and nonclinical information in a clear, respectful and timely manner. Provide and accept feedback in a respectful manner from all staff outside contacts Take Ownership Provide leadership to improve outcomes quality and service quality Work to ensure personal, departmental, and organization compliance with all legal and educational requirements Steadily improve the efficiency and economic aspects of your practice Change Embrace innovation to continuously improve patient care, service and organizational efficiency 25

26 Physician Review Form Integrates Results on: Quality Patient Experience Great Place Physician Compact Affordability Growth/Access Leadership Evaluation Tool (LET) 26

27 Potential High Moderate Low High Per for ma nc e Medium DC Low AD Talent Review Nine Box Physician Leadership Development Offerings Across the Career Spectrum Early Career Foundations of Leadership Book Group Emerging Physician Leader Learning Community Learning Community for High Potential Physician Leaders Mid Career Department Chair College Leadership Book Club Communication and Service Coaching Executive Roundtable Executive Level Customized Executive Development for Board and Medical Vice Presidents Administrative Excellence 27

28 Community Help to Increase Health of Population 28

29 La Crosse Medical Health Science Consortium Mission: Fostering collaboration for healthier communities Cultural Competency Healthcare Workforce Shortages Nurse Education Clinical Coordination Population Health Health Science Center La Crosse Compared to National Averages Advance Care Planning % of severely or terminally ill patient with an advance care plan % of physicians who are aware of the advance care plan Consistency between known care plan and treatment provided La Crosse Nationally J Am Geriatr Soc 2010;58:

30 1 st U.S. Health System Heated, Powered & Cooled by Local Renewable Energy We will improve health & lower cost Envision Demonstrate that "green" is a healthy, socially responsible and economically beneficial strategy. Face the Brutal Facts 2008 CO2 (pounds) 106,480,000 Mercury (pounds) 2.06 Particulate Matter* (pounds) 476, ,671, ,640 30

31 Lower the Cost 31

32 Fiscal Discipline A Success Story: Declining Fee Increase Trend 10.0% 9.0% 8.0% 7.0% 9.5% 9.3% 6.0% 6.6% 5.0% 4.0% 5.8% 5.5% 5.3% 4.9% 4.6% 3.0% 4.4% 4.3% 4.2% 4.1% 4.0% 3.9% 2.0% 1.0% 0.0% Gundersen Fee Increase 32

33 Board Mandate Keep the operating margin 3 5% No more Jeff Thompson, MD Chief Executive Officer 33