Advances in Osteopathic Medicine

Advances in Osteopathic Medicine Moving the value of osteopathic care from patients to populations Richard Snow DO, MPH Applied Health Services - Principal Choptank Community Health System Primary Care Physician Touro University College of Osteopathic Medicine-California Adjunct Faculty

Why Why we need to advance Osteopathic medicine? Current system Value to patients? Value to physicians? Goals Value Based Care Providing the best outcomes for your patients How Expanding the osteopathic culture from the patient to the healthcare system Leadership role in changing culture Using information to manage population Realigning patient and provider incentives for health What What do osteopathic physicians need to be successful? What does a reengineered healthcare system look like? Examples of value based care resulting in better health, better healthcare, lower costs and physician satisfaction

Osteopathic Medicine Any variation from health has a cause, and the cause has a location. It is the business of the osteopath to locate Why and Value? remove it (the cause), doing away with disease and getting health instead. A. T. Still MD, DO, Osteopathy Research and Practice Osteopathic Medicine Why Value? Value-based programs reward health care providers with incentive payments for the quality of care they give to people with Medicare. These programs are part of our larger quality strategy to reform how health care is delivered and paid for. Value-based programs also support our three-part aim: Better care for individuals Better health for populations Lower cost https://www.cms.gov/medicare/quality-initiatives-patient- Assessment-Instruments/Value-Based-Programs/Value- Based-Programs.html

Will your patients benefit? What does the current system give them now? Problem 1: Too Much Unnecessary Care Problem 2: Avoidable Harm to Patients Problem 3: Billions of Dollars are Being Wasted Problem 4: Perverse Incentives in How We Pay for Care Problem 5: Lack of Transparency https://www.forbes.com/sites/leahbinder/2013/02/21/the-five-biggest-problems-in-healthcare-today/#64e2e1994587

Underuse Institute Of Medicine Estimates of Waste in Health Care 30% of spending Overuse *Clinically Modifiable Waste https://www.nap.edu/read/12750/chapter/2#50

Where is the Value? Framework to identify opportunity gaps Underuse the failure to provide a service that is highly likely to improve the quality and quantity of life, is affordable and that the patient would have wanted Overuse the provision of medical services where the potential for harm exceeds the potential for benefit Chalkidou K, Doust J, et al. Evidence for overuse of medical services around the world. Lancet Volume 390, No. 10090, p156 168. DOI:/10.1016/S0140-6736(16)32585-5 Glasziou P, Straus S, et al. Evidence for underuse of effective medical services around the world. Lancet Volume 390, No. 10090, p169 177. DOI: /10.1016/S0140-6736(16)30946-1

Culture Patient and provider behaviors based on current beliefs Strength of Osteopathic Philosophy / Leadership Barriers to achieving Value Based Care Information How do we Identify waste? Explore opportunities Create and execute consistent methods of reducing waste? Key process deployment Incentives Assure that we are reducing waste and constantly improving? Program evaluation

Incentives A Changing Landscape https://innovation.cms.gov/initiatives/health-care-payment-learning-and-action-network/ Categories of Incentives (CMS Taxonomy) Category 1 fee-for-service with no link to payment quality; Category 2 fee-for-service with a link of payment to quality, and value; Category 3 alternative payment models built on fee-for-service architecture; and Category 4 population-based payment. Where are we now? 43% of health care dollars in Category 1 (e.g., traditional FFS or other legacy payments not linked to quality) 28% of health care dollars in Category 2 (e.g., pay-for-performance or care coordination fees) 29% of health care dollars in a composite of Categories 3 and 4 (e.g., shared savings, shared risk, bundled payments, or population-based payments)

Translating waste estimates to a small primary care practice. Total costs of care for an average 3 clinician primary care group across payers With estimates of waste using IOM Estimate of Per Member Per Year Costs to Payer Payer Number of Patients Total Payer Payments Medicare 2250 $11,400 $25,650,000 Commercial 1800 $4,100 $7,380,000 Medicaid 450 $7,010 $3,154,500 Overall 4500 $36,184,500 Waste at 30% (IOM Estimate) $10,855,350 Clinically Modifiable (15%) $5,427,675

Moving the mark Skills necessary to be successful in delivering value AMA Medical Education Consortium Curricular Domains Health Care Structure and Process Health Care Policy, Economics and Management Clinical Informatics Population Management Value Based Care

Moving to Value Osteopathic Medicine is already there Osteopathic Manipulative Medicine in Low Back Pain The Challenge of Perspective Value of conservative management of back pain Clinical impact of current, nonosteopathic, standard of care Unnecessary imaging exposure to radiation Unnecessary procedures exposure to adverse events Downstream costs of injections, surgery, other procedures Costs of opioid use / addiction

Osteopathic Manipulative Medicine in Low Back Pain What do we know? Conclusions from NEJM Article Osteopathic manual care and standard medical care have similar clinical results in patients with subacute low back pain. However, the use of medication is greater with standard care. Results The osteopathic-treatment group required significantly less medication (analgesics, antiinflammatory agents, and muscle relaxants) (P< 0.001) and used less physical therapy (0.2 percent vs. 2.6 percent, P<0.05). More than 90 percent of the patients in both groups were satisfied with their care. There was no statistically significant difference between the two groups in any of the primary outcome measures. A Comparison of Osteopathic Spinal Manipulation with Standard Care for Patients with Low Back Pain. Andersson G, Lucente T, et.al.n Engl J Med 1999; 341:1426-1431

Potential impact of conservative management of low back pain Evaluation of longitudinal costs associated with MRI in patients without red flag stratified by opioid use Defined cohorts of claims based severity Early imaging in less severe patients had on average $10,000 more in costs over the 12 months after LBP visit Driven by imaging, electrodiagnostic studies, injections, surgery Cascade of Medical Services and Costs due to Nonadherent MRI in Low Back Pain. Webster etal. Spine 2014;39:1433-1440

The CDC estimates that 1 of every 3 U.S. adults had prediabetes in 2010. Focusing on Value Based Care for at risk populations - Underuse Equates to 79 million Americans aged 20 years or older. 50% of all Americans aged 65 years and older have prediabetes. Without lifestyle changes to improve their health, 15% to 30% of people with prediabetes will develop type 2 diabetes (T2DM) within 5 years. https://www.cdc.gov/diabetes/basics/prediabetes.html Averaged 11% per year in DPP study

Can we modify the risk? N Engl J Med 367;13, Fradkin, Roberts & Rodgers. (2012). Lifestyle interventions reduced the development of T2DM by 58% during a 3-year period. The reduction was even greater, 71%, among adults aged 60 years or older. 10 year follow up, the lifestyle group still showed lower risk of diabetes compared to other groups, 34% reduction in progression at 10 years

Opportunity 16 Cost analysis identified doubling of healthcare costs for newly diagnosed diabetics ~$7,900/year What s the opportunity gap in my population? Example of an employed population Similar findings published out of Canada a year later* *Impact of diabetes on healthcare costs in a population-based cohort: cost analysisdiabet. Med. 33, 395 403 (2016)

Develop a rigorous plan to deploy the CDC Diabetes Prevention Program within the at risk population. How to we change the culture which encourages inaction? Identify individuals at risk POC HgbA1c testing during annual biometrics with offering immediate counseling to at risk individuals (HgbA1c 5.7 6.4) Provide free access to DPP classes OhioHealth, YMCA, Online Engage Marketing, Caresites and others in the message and accountability

Program Evaluation How do we make it better?

Culture and knowledge Changing care one population at a time Culture Change (Moving beliefs) Transition from diabetes is not a problem Diabetes is not preventable Change biometrics to include A1c Engage employees in enrolling Continue to reinforce success Information / Knowledge / Leverage Employer costs and productivity losses / Implications of disease state Results of RCT Key process indicator % of employees screened Key process indicator % of prediabetic employees attending at least 4 classes Program evaluation Incidence of diabetes in employee population

Post Acute Care (PAC) in Medicare Focusing on Value Based Care for at risk populations - Overuse Care that your patients get after discharge from hospital SNF, HHA, LTAC, IP,. Over a 90 day episode can represent 60% of total costs of care Medicare spending for PAC services exceeded $62 billion, comprising nearly 11 percent of Medicare (73% of variation in spending) Variation in Health Care Spending: Target Decision Making, Not Geography, Institute of Medicine, May 2013, The National Academic Press. Retrieved from: http://www.iom.edu/reports/2013/variation-in-health-care-spending-target-decision-making-not-geography.aspx

OhioHealth Experience Evidence base in managing post acute care clinical / financial outcomes Evidence base narrow Rich Article NEJM 1995 Heart Failure Challenge of creating a learning organization Testing hypothesis of improved care rigorously to understand how to improve clinical and financial outcomes Learning organization / change culture on the fly Bundled Payment for Care Improvement Gain Sharing with CMS for 90-day episode Coronary Artery Bypass Grafting, Surgical Valve Transcutaneous Aortic Valve Replacement

Exploratory Analysis 22

23 Care Redesign Setting patient & family expectations Use of AMPAC standard assessment tool Care Redesign: Developing Hypothesis and Measures of Key Changes Standardized hands-on training to family and caregivers Trained multidisciplinary team on role during discharge process Multidisciplinary team assesses readiness for discharge and barriers to discharging to home Determine if patient s functional level could improve if patient remains in hospital 1-3 days longer for additional therapy & training Increasing cardiac rehabilitation utilization Key Process Indicator Patients who received patient expectations letter from NP AMPAC assessments completed at each therapy visit Family & care givers trained by Rehab Adherence to standard work in discharge planning rounds Adherence to standard work for discharge planning rounds Cardiac rehab referral rate

24 Program Evaluation How do we make it better 41% Reduction 46% Reduction

Think of the whole patient Understand how the patient is being treated both in your office but also across all care they receive (continuum) Core takeaways that align with Osteopathic Philosophy Diagnosis how the patient interacts with their condition (mind and body) Identify where across the continuum the patient is/is not receiving care that may be harmful ---- diagnosis waste Understand how to bring the alignment of the patient directed towards health Identify the care redesign that balances the system towards the patient and creates better health, better healthcare and lower costs

The Association Between Health Care Quality and Cost A Systematic Review Ann Intern Med. 2013;158(1): 27 34. Recent articles and perspectives questioning approachs to population managements Effects of Care Coordination on hospitalization, Quality of Care, and Health Care Expenditures Among Medicare Beneficiaries JAMA. 2009;301(6):603-618 Cost Containment and the Tale of Care Coordination N Engl J Med 2016; 375:2218-2220 Focusing on High-Cost Patients The Key to Addressing High Costs? N Engl J Med 2017; 376:807-809