Transforming to Value: One Way Forward

Transcription

1 Transforming to Value: One Way Forward Intermountain Healthcare s Value-Based Reimbursement and Change Management Strategy Mark Briesacher, MD Senior Administrative Medical Director Intermountain Medical Group 1

2 Objectives As a result of this presentation, participants will be able to: Describe the key value strategies being employed by Intermountain and the Intermountain Medical Group Articulate why keeping population health management simple is important Apply what is learned to similar strategies for your physician group and health care delivery system 2

3 Intermountain Healthcare An Integrated Health System Intermountain Healthcare 1975 SelectHealth 1983 Medical Group

4 Intermountain s Mission and Vision Mission Excellence in the provision of healthcare services to communities in the Intermountain region. Vision To be a model healthcare system by continually learning and providing extraordinary care in all its dimensions. 4

5 We need to understand and redefine What it means to succeed as healthcare providers. What we reward in healthcare, and how we re going to do it. Our responsibilities as patients and as communities. These are interdependent and mutually reinforcing

6 Current Measures of Success The provision of more services (visits, diagnostic tests, and procedures) especially more technically complex tests and procedures Ratings by flawed criteria that measure processes rather than outcomes Powerful financial incentives drive current outcomes. "Every system is perfectly designed to get the results it gets. - Paul Batalden MD

7 Obstacles to Redefining Success Patients and providers may voice support for better outcomes, but many fear real change FOR PATIENTS Misperception that more is better when it comes to interventions & pharmaceuticals Advertising and a popular culture that feeds misperceptions FOR PROVIDERS 50 years of strong financial rewards from a fee for service environment

8 Redefining Success We prevent illnesses and injuries when possible When people do need care, we deliver measurably excellent outcomes consistent with best practice benchmarks We treat people with respect, and provide objective information so they can make informed decisions Individuals accept personal responsibility for their decisions and behaviors that impact cost and outcomes Together, we accomplish these at the lowest appropriate cost

9 Increasing Value in Healthcare Capture and use data to objectively track outcomes (cost and quality) Define opportunities for improvement Identify practices that produce best outcomes Implement those practices Re-measure outcomes and revise practices as needed

10 Physician-Involved Clinical Improvements Dixie NICU: Best Practices Implemented Elimination of unnecessary labs & tests Central line bundle Rapid glucose response teams Bubble CPAP versus ventilator Exclusive breast milk feedings and early feeding for low birth weight Early lung recruitment and appropriate use of oxygen Delayed cord clamping to increase blood hemocrit in neonate Near term/chorio infants placed on mother

11 Physician-Involved Clinical Improvements Dixie NICU Results

12 Physician-Involved Clinical Improvements Dixie NICU: Other Results NICU admissions down 17% (all OB admissions down 8%) NICU Length of Stay down 19% NICU staffs 3 or fewer nurses per shift (from 6-8) Average daily NICU census dropped to 3-5 infants (from 12-14)

13 Physician-Involved Clinical Improvements CT Pulmonary Angiogram: Optimizing for Suspected Pulmonary Embolus Objective: Reduce medical radiation Moderately high radiation Performed in all Intermountain hospitals primarily in the ED Estimated 20-30% of 20,000 annual studies at Intermountain were unnecessary Multidisciplinary team developed evidence-based guidelines and strategies for best practice

14 Physician-Involved Clinical Improvements CT Pulmonary Angiogram Results Guideline adherence increased from 45% to 70% in pilot (IMed) Initial numbers suggest 50% reduction from 2012 to 2013 in use of CT Pulmonary Angiograms in our emergency departments

15 We will be the medical group of choice in the communities we serve, working to improve the health and well being our patients. 15

16 Intermountain Medical Group 1,056 physicians 342 primary care 491 secondary care 86 hospitalists 17 radiologists 120 urgent care 265 advanced practice clinicians 5,116 total FTEs 16

17 Intermountain Medical Group Clinics and Services 165 primary or specialty care clinics 27 Instacare clinics 8 KidsCare locations 9 WorkMed locations 8 On-site employer clinics 5 Community/school based clinics 17 Retail pharmacies Hospital-based services (neonatal, Intensitivists, critical care, 17

18 Pathways to Value Reimbursement Integrated payer partner Contracted payer Medicaid Medicare Uninsured 18

19 Partners in Value Reimbursement Employed doctors and clinicians Health plan affiliated doctors and clinicians Medical staff doctors and clinicians Competitors 19

20 Common Solutions to Value Reimbursement DELIVERY STRUCTURES Primary care Aligned medical, surgical specialties Value based compensation DRIVERS OF CHRONIC DISEASE Hypertension Physical inactivity Depression SHARED RISK ON TOTAL COST OF CARE 20

21 Primary Care, Personalized Mass customization to common starting points Clinic based care management Patient activation strategies Value-based compensation Listen 21

22 Clinic Based Care Management Personalized Primary Care 1 RN Care Manager per 3-4 clinicians MA Health Advocate Results: Improved diabetes care Improved control of hypertension (pilot) Improved patient experience Encouraging trend: lower total cost of care

23 Intermountain Medical Group: SelectHealth members, diabetes bundle (N=4883) 38% 22% BP < 140/90 LDL < 100 HbA1c < 8 Annual nephropathy screening or ACE/ARB Eye exam every 2 years Today

24 Utah s cost burden of uncontrolled high blood pressure Most Expensive Chronic Diseases $435,000,000 Source: Utah Health Status Update: Uncontrolled High Blood Pressure in Utah, Utah Department of Health, July 2012

25 Improved treatment of hypertension is among the most important and quite possibly also the single most neglected area of clinical medicine. Only half of Americans with hypertension have blood pressure less than 140/90 mm Hg, Source: CDC, JAMA Viewpoint, 14 Nov 2013

26 As noted previously, health system wide implementation of focused evidence-based hypertension treatment algorithms together with regularly scheduled performance feedback within a coordinated multifactorial management program have been associated with substantially improved hypertension control in large populations and varied clinical practice settings.

27 Intermountain Medical Group: All payers, hypertension in control (N=93,129) 100% - 76% = 24% (22,351) NNT = 37 ¹ ¹ Colorado Permanente Medical Group, GPIN Fall Meeting, Oct. 2013

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30 Patient Activation: IndiGO Simulation model of human physiology, clinical events, and health behaviors Risk changes for heart disease, diabetes and some cancers Embedded within EMR work flow

31 Medical Conditions Improved with Exercise High blood pressure High cholesterol Diabetes Depression Heart disease Anxiety Arthritis Osteoporosis Fibromyalgia 31

32 Get Everyone Moving

33 Normalize and Social Mental Health Depression and anxiety frequently accompany chronic medical conditions and social challenges Many counties and regions do not have adequate mental health professionals to care for affected people 33

34 Mental Health Integration Model Proven to reduce utilization and improve outcomes, patient experience, doctor and clinician job satisfaction Model must be modified to provide support for all counties and regions 34

35 Intermountain Medical Group: Clinic Survey, % Excellent, Overall Experience with this Visit 64% 62% 60% 58% 56% 54% 52% 50%

36 Total Cost of Care Method of measuring health care affordability National Quality Forum endorsed measure developed by HealthPartners (MN) Optum Insight pediatrics and specialty Evaluates cost of care and amount of resource used

37 Value Based Compensation 85% productivity 15% value Clinical Excellence diabetes bundle Patient Engagement % excellent, overall experience Operational Effectiveness Meaningful Use, clinical documentation and coding Community Stewardship Mental Health Integration, advance directives, shared decision making, blood utilization, etc.

38 Value Recognition Program - Strategy Shared Accountability Physician Payment Beta SelectHealth Community Care Value Based Purchasing Regence BX/BS Medicare Advantage Meaningful Use United Medicare Advantage SelectHealth Medicare Advantage Core Measures, VBP PQRS Clinical Program Board Goals Other Payer P4P ICD-10 Value Recognition Program Medical Group Doctors and Clinicians

39 Shared Accountability: Three Key Elements Redesign care processes to promote greater use of evidence-based care as well as increasing efficiency Align financial incentives Develop and implement a physician payment model that recognizes Quality, Service, and managing the Total Cost of Care Develop and implement a comprehensive risk contract model for engagement with payers Engage patients in their care

40 Service Quality Physician Payment Model - Group Current Model All Fee for Service 100% FFS- Physician Service, quality and total cost of care have upside and downside risk Future Model Productivity 75% FFS- Physician Total Cost of Care 12.5% +/- 6.25% each, +/- 2.5% 17.5% upside

41 Beta Launch Work List 1. Establish measurements for quality, service, total cost of care 2. Agree on performance targets 3. Implement reporting tool 4. Establish a governance structure 5. Evaluate and propose beta parameters / participants 6. Recruit clinics to the beta 7. Amend physician contracts

42 Detailed Reporting on Quality, Cost, and Service Claims Based Cost of Care Data EDW Data Marts Patient Experience Data Web-based Reporting Platform End Users Physicians Claims Based Quality Measures Intermountain Clinical Data Risk Stratification Data Admit, Discharge, & Transfer Data Care Managers Administrators Patient-level detail Condition-level detail Procedure-level detail

43 Detailed Reporting on Quality, Cost, and Service

44 Resist change and die, accept and survive, lead and prosper. Michael Leavitt Former Secretary of Health & Human Services

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