Transforming Delivery Systems for Improved Population Health

Transcription

1 Transforming Delivery Systems for Improved Population Health George Isham, M.D., M.S. Senior Advisor, HealthPartners Senior Fellow, HealthPartners Institute for Education and Research March 23, 2016 It is amazing how little you are able to do with so much! A visitor to the US from Finland Some Recent Trends - 1. Reform 2. Consolidation 3. Payment: From Volume to Value 4. Populations are now a focus 5. Increasing Transparency 6. New and Non-Traditional Competitors 1

2 and Relative to the Triple Aim - 7. Deeper Emphasis on the Cost (Level, Rate of Increase and Market Position for individuals as well as populations) 8. Health and Well-being of Individuals and In the Community (Health Care, Behaviors, Socioeconomic and Environmental factors) 9. Deeper Mastery of the Experience (beyond patient satisfaction + clinical quality). Note: New Systems are playing catch-up on Quality for Populations of Patients (Population Management) So let s talk a bit more about the components of value - Cost Health Quality Cost 2

3 About 3 years lower life Expectancy in the U.S. For the US Population about $4,000 per capita or about $1,246,367,668,000 in the aggregate U.S. Waste Estimate: about $765 Billion, or about $2,455 per capita (IOM: 2010) (US Population as of July 2011 = 311,591,917) Crowding Out Education - In Massachusetts, inflation adjusted health care increased by 81% in the past 15 years while spending on education fell by 27%. In Minnesota over the next 25 years, it is predicted that each year health care costs will increase by 8.5%, state revenues by 3.5% and education costs by 0.2%. Fazio C & Kottke T. A Paradox of Well Being. Star Tribune. February 16, 2015 Is a reduction in the cost of health care a health improvement intervention? 3

4 A New Ethic Around Financial Thinking in Health Care? Level 1: Need Good Institutional financial management adequate margins and bond rating (Be financially responsible) Level 2: Keep cost and price increases under inflation (Do no further harm to society) Level 3: Support a market dynamic that results in lower total cost of care (Be a part of the solution) Health & Well-Being Clinical Care - Not the Primary Determinants of Health Only 20%! Clinical Care Underlying Determinants of Health 50% County Health Rankings Model. Copyright 2010 UWPHI (Annotated by Isham) 4

5 Figure Out Your Relationships to the Broader Determinants of Health Key Outcome Improved Health (as measured by a Summary Measure of Health) Health Determinant Health Care (20%) Health Behaviors (30%) Socio economic factors (40%) Environmental Factors (10%) Primary Drivers Preventive Services Acute Care Chronic Disease End of Life Cross Cutting Issues Tobacco Non use Activity Diet/Nutrition Alcohol Use Community Identified Drivers (Advocacy and Participation Community Identified Drivers (Advocacy and Participation Mission, Capabilities, Control Central to Mission Many Capabilities High Control Central to Mission Shared Capabilities Shared Control Aligned with Mission Limited Capabilities Limited Control Modified from Isham G and Zimmerman D, HealthPartners Board of Directors Retreat, October 2010 Determine a Role for your Organization Example: HealthPartners Community Efforts - Advocacy for fluoridation of water supply Yum power school challenge Honoring choices initiative Make it OK campaign Saint Paul promise neighborhood initiative Children s health focus for 2014 and beyond Quality of Care 5

6 Consider Improvement Beyond Clinical Care Level 1: Traditional Clinical Care Looking for those opportunities to improve care (e.g. disparities, health literacy, social factors) Level 2: Population Management Utilization of services, service quality, quality of care, total cost of care Level 3: Population Health Addressing those broader factors that lead to improved well-being & length and quality of life Triple Aim: Transformation Elements* Align compensation, payment, and plan benefit design with Triple Aim goals Set goals; aim high Redesign Care Reliability Customization Access Coordination Transparently report results Culture Proactively identify and engage high risk populations Provide actionable Triple Aim data Support healthy lifestyle choices *HealthPartners, 2012 Some Key Drivers of Transformation Organizational and Operational Excellence Mission, Vision and Values Connection and responsiveness to stakeholders Reliable Execution of Innovative Ideas and the routine stuff Better use of Information Performance Transparency Decision support Population insight/individual insight Stratification for focus of effort Relationship Innovations Partnerships, Combinations, Consolidations Payment Model Innovations Fee for Service changing to Shared Savings and Shared Risk 6

7 Key Learnings Care Delivery Financing Use a standardized operational model, regardless of the financial model Reality: financial models vary Look for directional consistency to take action on improvement Focus on a manageable, but meaningful set of measures Partnership and data sharing among payers and providers improves Triple Aim results HealthPartners and the Triple Aim HealthPartners: Aspiring for our Best with Triple Aim Triple Aim Mission Vision Values To improve health and well being in partnership with our members, patients and community. Health as it could be, affordability as it must be, through relationships built on trust. Excellence, Compassion, Partnership, Integrity. 7

8 What is Total Cost of Care? Translating Information to Action Quarterly Reporting Financial View Benchmarking View Patient Level View Contract performance monitoring Practice performance compared to peers Identify areas of opportunity to drive Improvement By condition and episode Referral partner use and performance Pharmacy use and generic prescribing Support care redesign and practice improvement Detailed information allows care systems to create customized analyses Includes information like predicted risk, ED, hospital use and physician prescribing profiles Improvements TCOC reporting supports identification of drivers of health care cost today. Do these things Keep people healthy Preventive care Engaging patients in healthy lifestyles Coordinate care between providers and locations Better care for patients with chronic conditions Provide evidence based care Chronic conditions Procedures and surgeries Appropriate use of generics, imaging and lab Engage patients in decisions about care Shared decision making Patient centered care Avoid harm Hospital acquired infections Focus on efficient use of resources while maximizing health and experience outcomes To avoid these things: Avoidable admissions/readmissions Avoidable emergency room visits Unnecessary lab testing Use of higher cost drugs when a generic is available Unnecessary use of hi tech diagnostic imaging (MRI & CT scans) 8

9 Provider Payment January December Quarterly Year End Claims paid to providers Performance Reporting Triple Aim Goals met: Shared savings paid to the provider Pool built from provider payment $ Electronic tools to support patient level care coordination or Goals not met: withhold plus interest returned to the employer Multiple Levels of Transparency Population Based TCOC Performance Condition Based TCOC Performance Procedural bundled price transparency Service specific price transparency Creating a System: Culture 9

10 Our Physician Culture Care Design Care Design Principles We use the following design principles to ensure our care achieves Triple Aim results: Reliability Customization Access Coordination Reliable processes to systematically deliver the best care Care is customized to individual needs and values Easy, convenient and affordable access to care and information Coordinated care across sites, specialties, conditions and time 10

11 Care Design Principles Reliability Customization Access Coordination Throughout our system we develop consistent approaches to deliver reliable, standardized care focused on the patient: Evidence based Decision support in electronic medical record Processes are standardized Defined roles and responsibilities Every member of the care team contributes to their maximum potential Waste and rework eliminated through Lean and process redesign techniques Care Model Process Before the Visit During the Visit After the Visit Between Visits Visit Scheduling Pre-visit Planning Check-in Visit Follow-up Between Visits Modules in Place Visit Scheduling Pre Visit Planning Check in/check out Visit After Visit Summary Test Result Reporting Standardized Call Back Requirements Advance Directives Chronic Care Disease Registry In basket Management Medication Refills Opioid Management Patient Communication Team Members Physician Led Registered Nurse Rooming Staff Clerical Staff Ad hoc: dieticians, diabetes educators, pharmacists Care Design Principles Reliability Customization Access Coordination First we standardize to the science; then we customize care to individual patient preferences and values and unique human characteristics 11

12 Care Design Principles Reliability Customization Access Coordination We design ways to make care and information: More convenient Easy to access; and Affordable Online Services 36% of Patients enrolled Lab results automatically shared online with patients; most within 4 hours Over 18.8 million results-to-date To 155,176 patients Access medication list and immunization records Refill prescriptions and mail order pharmacy Online appointment scheduling (7.7% of all appointments) Online bill pay Secure with doctor, nurse Access After-Visit Summary Care Design Principles Reliability Customization Access Coordination We coordinate care across sites, specialties, conditions and time 12

13 Care Coordination Support: Predictive Modeling as an input to Stratify Patients Benefits beyond only using claims data Added layers of severity of condition (labs, assessments, etc.) Enhanced social history documentation above claims Diagnoses otherwise not captured in claims (i.e., problem list) Prescription orders that are not filled Surgical and procedure history less available on transient plan populations Predictive Modeling Implementation Identifying High Risk Patients All HealthPartners hospitals have care management/care coordination resources Predictive modeling data is used in Ambulatory Care Conferences Predictive modeling data is automatically loaded into the electronic health record monthly for all patients within legacy HealthPartners Medical Group and Stillwater Medical Group Example of Predictive Modeling Data in the Electronic Medical Record Name/ Age/ Gender Tier 4 Hospitalization Risk Last Hospitalization Case Manager? Next Primary Care Visit John Smith 45 M Paula Brown 87 F Sally Adams 63 F Tier 4 12/30/2013 Yes 4/08/2014 Tier 4 01/15/2014 No 3/15/2014 Tier 4 02/23/2014 Yes 5/02/

14 Thinking about the Role of Analytics in Health Systems Thinking about the Role of Analytics: Descriptive Analytics: What happened? Diagnostic Analytics: Why did it happen? Predictive Analytics: What is likely to happen in the future? Prescriptive Analytics: So what should we do about it? What do we want to use Analytic Capability to Anticipate? Clinical/Care Risk Personal Capability Personal Preference 14

15 When health is absent, wisdom cannot reveal itself, art cannot become manifest, strength cannot be exerted, wealth is useless, and reason is powerless. Herophilus, ancient Greek physician Appendix 1: Some Recent HealthPartners Triple Aim Performance Results Health Plan 1.5 million members Medical Clinics 1,700 physicians 50 primary care locations 55+ medical specialties Dental Clinics 60 dentists across 22 clinics 6 dental specialties Hospitals 6 hospitals Level 1 trauma and tertiary center Acute care hospitals Critical access hospitals Consumer governed, non profit Integrated health and financing 22,500 team members 15

16 Stewardship: Company Performance Optum Insight Benchmark For five years, HealthPartners Total Cost of Care has been lower than Minnesota and regional benchmarks. Minnesota Benchmark Regional Benchmark 17% 8% Health: Company Performance Readmission Rates % 13.2% 15.6% 5.8% 6.7% 8.8% HEDIS Plan All Cause Readmissions Index Observed to Expected (lower is better) Regions Methodist Lakeview Hudson Westfields Amery 30 Day All Cause Readmissions (year to date, lower is better) Experience: Company Performance How would you rate? 100% Goal 84.7% 80% 80.6% 83.8% 86.2% 87.4% 81.7% 82.9% 79.4% 73.1% 75.0% 79.8% 84.2% 77.9% Goal 81.5% 69.2% 60% 40% 20% 0% n/a HPMG Park Nicollet Stillwater HP Central MN Rate your provider (Primary care/specialty care) Regions Methodist Lakeview Hudson Westfields Amery How would you rate this hospital? Year to date, Goal: Top decile 16

17 Experience: Company Performance How would you rate? 100% 80% 75.59% 77.90% 75.72% 60% 64.70% 66.90% 65.27% Goal 90 th Percentile 40% 20% 0% * Rate your health plan (CAHPS) Minnesota Community Measures Highest Performing Medical Groups in 2014 (Primary Care) HealthPartners Clinics Park Nicollet Health Services Fairview Health Services Measure 13 out of out of out of 18 ADHD Adolescent Immunizations Breast Cancer Screening Bronchitis Childhood Immunization Status (Combo 3) Chlamydia Screening Colorectal Cancer Screening Controlling High Blood Pressure COPD Depression Remission at 6 months Depression Remission at 12 months Maternity Care: Primary C Section Rate Pharyngitis Optimal Asthma Care Children Optimal Asthma Care Adults Optimal Diabetes Care Optimal Vascular Care URI = Medical Group rate and CI fully above average Blank = measure reported but rate was average or below average Integrated system lift on quality Significant portion of our health plan members receive care in our medical groups HEDIS Rating High quality performance of our care group contributes to high performance of the health plan We are the top health plan in Minnesota High performing nationally with 4.5 rating out of 5 17

18 Diabetes Care Teamwork is a key skill Doctor and RN shared visit Proactively identify patients using a registry Reach out to patients who need to come in for a visit or need support between visits Increasing use of technology e.visits/tele-health Engage patients in healthy lifestyle choices ( health coaching ) Optimal Diabetes Care Blood pressure under control ( 139/89) Cholesterol: LDL ( 99)* Blood sugar under control (A1c 7.9) Non smoker Regular aspirin user, if vascular disease is present *Under revision Saves 403 hearts, 40 legs & 760 pairs of eyes each year HealthPartners 35,646 members with diabetes in 2014 suffered 403 fewer heart attacks, 40 fewer leg amputations and 760 people did not experience eye complications compared to what would have happened to the same 35,646 plus members in Notes Current Optimal Diabetes definition = Patients with diabetes (Type 1 or 2) ages who reach four treatment goals: 1) Hemoglobin A1c less than 8. 2) Blood pressure less than 140/90mm/Hg. 3) Daily aspirin use for patients with a co morbidity of Ischemic Vascular Disease (IVD) unless contraindicated, and 4) Documented tobacco free status. Optimal Diabetes Rates taken from HealthPartners yearly Clinical Indicators reports for years Rates for are pulled from Minnesota Community Measurement (MNCM.org) for the HealthPartners insured population. A1c definition was <=7 for years A1c definition was < 7 for years A1c definition from 2009 to current is < 8. Blood pressure definition was <130/80 for years The LDL C less than 100mg/dL component was removed from the Optimal Diabetes definition for This change created the substantial increase in Optimal Quality in Diabetes Outcomes by Race 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% LDL goal: <100 A1c goal: <8.0 BP goal: <140/ % 55.7% 2014 HEDIS national 90th percentile 74.9% 67.6% 67.3% 67.5% 2014 HEDIS national 90th percentile 89.7% 85.6% 75.2% 2014 HEDIS national 90th percentile % Met LDL Goal % Met A1c Goal % Met BP Goal White (n=9,980) Patients of Color* (n=3,827) *Patients of color: includes patients whose self identified race is either American Indian or Alaska Native, Asian, Black or African American, Hispanic or Latino, Some other race, and patients with more than one race documented (Multiple race) 18

19 Appendix 2: Some Definitions Some Definitions - Health Care: The Maintenance or restoration of health by the treatment and prevention of disease especially by trained and licensed professionals. (MW) Quality of Health Care: The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. (IOM, 1990) Health: Physical, mental and social well being, not just the absence of disease (WHO, 1946). Population Health: The health outcomes of a group of individuals including the distribution of those outcomes within the group (Kindig & Stoddard, 2003) (Length of Life and Quality of Life) Well-being: Life Satisfaction. (Kottke, Steiffel & Pronk, 2016) Value: Something that can be bought for a low or fair price. (MW). i.e. outcomes achieved/resources expended MW = Online Merriam Webster Dictionary 19