NCSL Winnable Battles Harry Reynolds IBM June 6, 2011 Market forces require a new approach for the health care industry Health care is shifting from local to national and global contexts Empowered consumers expect better value, quality, and outcomes Incidence and cost of chronic and re-emerging infectious diseases are increasing Industry Challenges and Opportunities Changing demographics and lifestyles drive associated costs 2 Costs are growing for new, revolutionary technologies and treatments Source: IBM HCLS, IBM GBS Institute for Business Value Primary Care and Nursing shortages demand workforce productivity and efficiency New market entrants and new approaches to health and care delivery increase complexity and competition 1
Trends, Reactions, Assumptions in the U.S. Provider consolidation is accelerating Medical Homes are in demand ACO s are evolving and re-defining partnerships Competitors are merging, payers/providers are merging New places and types of care are on the increase Quality is required for both processes and outcomes Providers will know and market their quality and outcomes Consumer health will be the mantra PBMs, Labs, Pharmacies, and Retail Sites are engaging aggressively Hospitals are evaluating a revenue shift to coordinated care The tools available as you approach Winnable Battles Global and national best practices at your local sites Tools to Empower Populations before, during and after treatments Technologies and information to reduce readmissions and hospital infections Realistic opportunities to make a difference Analytic capabilities to address the varied demographics and life service preferences Access to new technologies to allow lesser cost venues to be prevalent and more patient-centric Source: IBM HCLS, IBM GBS Institute for Business Value 4 Benefits, care models, processes and information specific to the person and disease New partners and best practices from health care and other industries 2
IBM Employee Health Impacts HEALTH CARE COSTS Medical claims Pharmacy claims Behavioral health Care management costs Admin. costs ABSENTEEISM Short term disability Long term disability Unplanned vacation Dependent care PRESENTEEISM Cognition Distraction Interruption Engagement Resilience Flexibility 2010 IBM Corporation IBM Value and AffordabilityJourney Health Care trend is 53% Lower over 2004 2009 than in 2000 2003 IBM Net Health Care Trend Over Time 14.0% 13.3% 33% Average Trend During 2000-2003 is 8.5% per year 12.0% 10.8% 10.0% 9.3% Average Trend During 2004-2009 is 4.2% per year 8.0% 6.8% 6.0% 4.8% 4.3% 4.0% 3.1% 3.2% 3.1% 2.7% 2.0% 0.0% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Changed Subsidy Approach Changed Health Plan Strategy Changed Purchasing Strategy: best in market discounts/ administrative fees Attacked Population Health: to stem pipeline of risk Reduced percentage of employees with high health risks by 55% Over 80,000 IBMers are physically active New Metrics to drive decision making and smart consumption: e.g. generic utilization increases to 96% voluntarily Source for benchmarks: Average of survey results from Kaiser Family Foundation, Hewitt Associates, and Towers Perrin 2011 IBM Corporation 3
Payers/Providers have many initiatives underway, but will the health consumer buy in and engage in their own health? More to Come Reimbursement models Accountable Care Organization HIE Medical Home High Value Care Quality Outcomes Meaningful Use New Delivery Models 2010 IBM Corporation Initiating the personalization of care Asthma is one of the diagnoses included typically included in Disease Management programs. In a commercial product, it is typically the program with the largest patient load (close to 15% of eligible members). The diagnoses on the right, in red font, are more specific asthma diagnoses that will allow Plans to develop targeted programs, stratify members more effectively, and reduce the occurrence of false positives. Asthma ICD-9 CM Extrinsic vs. intrinsic Chronic obstructive asthma With status asthmaticus With exacerbation Exercise induced bronchospasm Cough variant asthma Asthma ICD-10 CM Mild intermittent Mild persistent Moderate persistent Severe persistent With status asthmaticus With exacerbation Exercise induced bronchospasm Cough variant asthma Excludes chronic obstructive asthma 2010 IBM Corporation 8 4
DIABETES ICD 9 CM 22 codes to report Diabetes Takes multiple codes to report the diabetes and any associated manifestations of the disease. ICD 10 CM 318 codes to report Diabetes The reason for the large number of codes in ICD 10 CM: combines the diabetes & the multiple diabetes manifestations into a single code & can even define and capture the use of insulin with a code Allowing for a more clinically complete description of the codes reported LFord Consulting LFord ConsultingSource: NCHIMA North Carolina Health Information Management Association OBESITY ICD 9 CM Three codes representing obesity Unspecified Morbid Overweight ICD 10 CM Seven codes representing obesity Morbid due to excess calories Drug induced obesity Morbid with alveolar hypoventilation Overweight Other & unspecified obesity LFord LFord Consulting Consultimg LFord ConsultingSource: NCHIMA North Carolina Health Information Management Association 5
CONGESTIVE HEART FAILURE ICD 9 CM 15 different codes representing heart failure and the type of failure ICD 10 CM 50 different codes and code combinations depending on the type of heart failure, reflecting a more clinically i ll specific profile of the heart failure LFord LFord Consulting Consultimg LFord ConsultingSource: NCHIMA North Carolina Health Information Management Association PATIENT NONCOMPLIANCE ICD 9 CM Currently only reported as one code: V15.81 Noncompliancewithmedical medical treatment ICD 10 CM Expanded to 8 codes: Z91.11 Patient's noncompliance with dietary regimen Z91.120 Patient's intentional underdosing of medication regimen due to financial hardship Z91.128 Patient's intentional underdosing of medication regimen for other reason Z91.130 Patient's unintentional underdosing of medication regimen due to age related debility Z91.138 Patient's unintentional underdosing of medication regimen for other reason Z91.14 Patient's other noncompliance with medication regimen Z91.15 Patient's noncompliance with renal dialysis Z91.19 Patient's noncompliance with other medical treatment and regimen LFord Consultimg LFord ConsultingSource: NCHIMA North Carolina Health Information Managemetn Associaiton 6
Member 360 Adjusting the Perspective Am I getting the most for my spend? Who can help me make better care choices? What s the overall health of my organization? What Wellness/ fitness programs are most effective? How do I compare with my peers? Am I rewarded for quality? What is the success of my Diabetes Mgmt Program? What about my Smoke Cessation Program? What new products/ programs can I introduce? What value-add services? How fast am I recognizing and acting on high cost cases? 13 Demandsystem What are my healthcare costs? Who are my high utilizers? 2011 IBM Corporation Considering your population by segment? Which channels of information are the most effective for engaging different segments? Which segments can Winnable Battles influence the most? Which segments will provide the most positive impact? How personal can you make the care, information, tools and benefits? 2011 IBM Corporation Note: Bubble size is illustrative and not to scale. The conditions included in this figure as examples represent only a subset of the overall size of the segment. 7
Analytics Maturity Landscape Are you aligning your information? Analytics embraced & integrated into every day decisions & operations Operational buy in to performance analysis driving decisions Performance messages widely communicated Single version of truth Pride in the gut based decision Basic Significant manual input Communication & Culture Test and Learn Culture Robust feedback loop Descriptive Analytics Spreadsheets Advanced Analytics Performance Metrics Data warehouses, governance and production reporting Breakaway Passionate sponsor of analytics Intelligent Integrated information Isolated reporting & analysis systems DRAFT Leverage crossdepartmental & functional data to derive actionable insight Collaboration & workflow tools to aid planning & info sharing Personalized & role based portal Automated analysis/alert Contextual business rules Predictive modeling Monitoring, Prediction, Action Leverage structured & unstructured data for decision making Adaptive Machine Learning Real Time Decision Support prototypes Decision support systems for collaborative care Patient Similarity Assessment Outcome Measure: HbA1C Level Positive Outcome Negative Outcome (blue) Optimal Physician Prediction Physician Outcome Modeling Physician??? Patient 16 2011 IBM Corporation 8
The current state of health devices There is a proliferation of digital devices that captures data and is (or will be) connected Health Care devices as an extension of care! How do they affect health outcomes? Are they included in your benefits? Who coordinates the information? Can they be a key inclusion in: Winnable Battles? Weight Scale Bloodpressure Glucose Meter Thermometer Pulse Oximeter Cholesterol Monitor Home sensing & control Bed / Chair Sensors Implant Monitors Spirometer Medication Tracking Baby Monitors PERS Pedometer Fitness equipment Consumer Electronics Sources: WHO definitions; IBM Institute for Business Value Analysis 2011 IBM Corporation What is a SmartRoom? A smart patient room that Organizes the workflow of front-line staff to simplify and improve the quality and safety of care giving Makes retrieving the right patient information at the right time as simple as walking into the room Enhances the documentation of patient information in the patient s room and the nurse s station Engages the patient and their family through improved communication, education and entertainment 9
Health Benefits to Consider for Specific Diseases Transportation Drug co-pay waivers Home devices Case thinking for specific diseases Monitoring in retail settings Home visits Nurse coordinators for discharge handoffs and patient transition Pharmacist consultations Health Risk assessments with incentives and personalized (50%) Personalizing Care, benefits and outcomes Diagnosis- (ICD10) Care Models by diagnosis Quality based on diagnosis and meaningful use Outcome analytics and similar patients Benefits flex by diagnosis and personal characteristics of each patient Care settings are varied and local (neighborhood or aligned providers) Monitoring is personal and uses preferred technology Patient buy-in is requested, recommended and required Primary care is a foundation that is enthusiastically embraced Disease maintenance is inherent and personalized 2010 IBM Corporation 10
The Call to Winnable Battles Exciting approach Never a better time Never more care models and technologies available Current approaches are lacking Each of you is affected Each of you is defining a real approach and an answer The industry is ready to assist What a great legacy to create 11