Transforming Delivery Systems for Population Health

Transcription

1 Transforming Delivery Systems for Population Health George Isham, M.D., M.S. Senior Advisor, HealthPartners Senior Fellow, HealthPartners Institute for Education and Research October 9, 2015

2 Presenter has no financial or non-financial potential conflicts of interest relevant to this presentation.

3 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) Value: Something that can be bought for a low or fair price. (MW). i.e. outcomes achieved/resources expended MW = Online Merriam-Webster Dictionary

4 Some Trends - 1. Reform Legislation Increases Coverage, Encourages Automation (EHRs), Encourages Consolidation (ACOs), Shifts Payment from Volume to Value 2. Consolidation of Providers and Payers is actually occurring. 3. Increasing Transparency for Purchasers & Government & the Public 4. Purchasing shifting from Group to Individual & Commercial to Government? (via exchanges,?via purchaser exit of group purchasing market?) 5. Payment shifting from Volume to Value.

5 Some Trends - 6. New Competitors see many opportunities to create value for individual & group purchasers (Minute Clinic, online app start ups, etc.) 7. The Triple Aim A. Deeper Emphasis on the Cost (Level, Rate of Increase and Market Position) and B. Health In the Community (Health Care, Behaviors, Socioeconomic and Environmental) legs of the triple aim, C. and deeper mastery of the Experience leg (beyond patient satisfaction + clinical quality). New Traditional Systems are playing catch-up on Quality for Populations of Patients (Population Management)

6 So let s talk a bit more about the components of value - Cost Health Quality

7 Cost

8 Drivers of health Where money spent 20% Medical services Facing the challenges in health care 30% 40% 10% Healthy behaviors Social and economic factors Physical environment 88% 8% Other Medical services 4% Healthy behaviors

9 = $765 Billion (IOM, 2010)

10 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 (US Population as of July 2011 = 311,591,917)

11 Health-care related spending crowds out expenditures on social goods including education, economic development and maintenance of critical infrastructure. Bradley, EH et al BMJ Qual Saf 2011;20:826e831.

12 Education & Health Not finishing high school can be as bad for your longevity as 30 years of cigarettes Life expectancy for white women without a high school diploma fell five years between 1990 and The more highly educated can compete for betterpaying jobs. They can afford healthier foods and homes. They face less stress and uncertainty, and they tend to have healthier lifestyles. Importantly for the community, studies show they re also more likely to be employed and self-sufficient Fazio C & Kottke T. A Paradox of Well-Being. Star Tribune. February 16, 2015

13 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

14 What Could $750 Billion the Health Dividend Do? Private $412b Increase business investment: add jobs, international competitiveness Bolster economic growth: increase wages, leisure, consumer purchases Increase living standards Public $338b Stabilize the nation s fiscal health Address failing infrastructure Improve the population s well being Ensure the Nation s Defense McCullough J, Zimmerman F, Fielding J, Teutsch S. A Health Dividend for America The Opportunity Cost of Excess Medical Expenditures. Am J Prev Med 2012;43(6): Modified by G. Isham, August, 2015.

15 Is a reduction in the cost of health care a health improvement intervention?

16 Address Cost Management More Broadly and Aggressively 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)

17 Health

18 Clinical Care - Not the Primary Determinants of Health Only 20%! Clinical Care Underlying Determinants of Health 50% County Health Rankings Model. 18 Copyright 2010 UWPHI (Annotated by Isham)

19 Figure Out Your Relationships to the Broader Determinants of Health Key Outcome Health Determinant Primary Drivers Mission, Capabilities, Control Improved Health (as measured by a Summary Measure of Health) Health Care (20%) Health Behaviors (30%) Socio-economic factors (40%) Environmental Factors (10%) 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 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

20 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

21 In addition to excellent health care, what are one or two things you are doing in your practice to advance population health?

22 Quality

23 Triple Aim: Transformation Elements* Set goals; aim high Align compensation, payment, and plan benefit design with Triple Aim goals 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

24 The Key Drivers 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

25 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

26 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 length and quality of life

27 HealthPartners and the Triple Aim

28 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

29 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

30 A Unique Point of View Care Delivery Patient-centered approach Supportive partnerships Robust, actionable data Process improvement consultation Integrated/complementary health management Financing TCOC value-based payment approaches 30

31 What is Total Cost of Care? Understanding what is driving health care costs and outcomes is important to ensuring health care affordability and positive results. In order to have a common measurement system, HealthPartners developed Total Cost of Care (TCOC) measures to pinpoint ways to make health care more affordable and reduce trend without sacrificing quality or experience. 31

32 32 What is Total Cost of Care?

33 Translating Information to Action Quarterly Reporting Financial View Contract performance monitoring Benchmarking View Patient-Level View 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 33

34 Improvements TCOC reporting supports identification of drivers of health care cost today. 34 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)

35 Partnership with Providers on the Triple Aim HealthPartners Solutions Align Incentives/Payment Reform -Total cost of care bundled payment Actionable Health Information - Quality results - Patient experience Utilization Measures - Price and utilization benchmarking - Referral partners - Case for conditions 35 Population Health Solution - Disease management - Case management - Health assessment - Health & wellbeing programs Partnership Improved Health Better Care Reduced Costs Care Delivery Transformation Reliable Evidence-Based Practices - EHR decision support - Care team redesign - Standardized, evidence-based Patient-Centered Care - Shared decision making - Customized care Convenient, Affordable Access - Easy access - Phone visits, evisits - Online services Coordination of Care - Strong transitions across primary, specialty & hospital - Reducing readmissions

36 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

37 Triple Aim Shared Savings Provider maintains benchmark quality performance Shared Savings approach for achieving TCOC targets Targets are set based on a providers own performance and/or Achieving market based targets There must be actual savings tied to achieving TCOC targets or Shared Savings is not paid out

38 Multiple Levels of Transparency Population- Based TCOC Performance Condition- Based TCOC Performance Procedural bundled price transparency Service specific price transparency

39 Web and Mobile Transparency

40 Value-based exchange product Develop Accountable Care Organizations Add to exchange product based on Total Cost of Care CareChoices Preferred Care System Options Employee Contribution Defined Contribution Amount $36 $37 $46 $47 $47 $48 $60 Employer Contribution $100 $100 $100 $100 $100 $100 $100 Tier 1 Providers HealthPartners HealthEast Physicians Park Nicollet Health Services Fairview Clinics Allina Medical Clinic Open Access

41 Creating a System: Culture

42 42 Our Physician Culture

43 43 Partnership Agreement Example

44 44 Benchmark Against Other Practices

45 Care Design

46 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 46

47 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 47

48 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 Visit Scheduling Pre-Visit Planning Check-in/Check-out Visit After-Visit Summary Test Result Reporting Standardized Call Back Requirements 48 Modules in Place 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

49 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 49

50 Care Design Principles Reliability Customization Access Coordination We design ways to make care and information: More convenient Easy to access; and Affordable 50

51 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 51

52 Care Design Principles Reliability Customization Access Coordination We coordinate care across sites, specialties, conditions and time 52

53 Care Coordination Support: Predictive Modeling as an input to Stratify Patients 53 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

54 Complementary Support Care and Disease Management Care Team Patient Proactive Supportive & Enhancing Care Two-way communication 54