New Model of Care: 1 Year Post IHI

New Model of Care: 1 Year Post IHI BY: Kristie Genzer, System Vice President of Physician Development President of Ochsner Physician Partners Robert Hart,MD Regional Medical Director D16/E16 This presenter has nothing to disclose Here is text for the textbox December 11, 2013 9:30 a.m./11:15 a.m. 1 Session Objectives Transition from a volume-based to a value-based practice Develop strategies to implement the Triple Aim model 2 1

Ochsner Health System Jan 2, 1942 3 Ochsner Health System: Physician-led, not-for-profit healthcare system Clinical Integration Network of 1100 MD s 1 st Artificial Heart Transplant in Gulf South Region 1 st in utero surgery in the Gulf South region Ochsner Clinical School affiliation with University of Queensland Programs: EICU, Stroke and Psych Tele-medicine EPIC Integration:8 hospitals and 49 health centers 4 2

Why Ochsner Exists. Our Goal is to Keep People Well and Functioning -Alton Ochsner, MD Ochsner Strategic Direction STRATEGIC IMPERATIVES Community: Serving the greater need People: Our most valuable asset. Quality: Error-free care that s affordable Academics: National leader with global Impact. Stability: Financially sustainable and growing Loyalty: Patients, families & physicians 3

Our Nation s Healthcare.. The US pays over 2 trillion dollars, considerably higher than any other developed country (Kumar and Nash 2011) Ascent of health care expenditures to approx 18% of GDP is not sustainable 38th on the World Health Organization s rankings of world s health systems? $700 billion of care is characterized as waste or unnecessary. Patient Protection and Affordable Care Act (PPACA) signed into effect on March 23, 2010 by President Obama 7 The Health of Louisiana Highest rates of obesity, diabetes, chronic renal disease, and heart disease. Louisiana consistently ranks in the top 90%ile of health care spending. The state is challenged economically with a low per capita income, large Medicaid population, and a financially-strained state economy. 8 4

Ochsner Baton Rouge Region One Hospital, 9 Health Centers, 101 MD s, 41 APC s and 1100 Employees Only fully integrated multi-specialty group practice in Baton Rouge to include a hospital facility Largest area certified nurse midwife program Ochsner Medical Center - Baton Rouge received the Gold Level Hospital Quality Award from the Louisiana Health Care Review (LHCR) in 2008 and 2009 1 of 23 GYN Epicenter sites in the nation for roboticassisted surgery Now offering general surgery options such as GERD treatment and colon cancer removal with the da Vinci 9 10 5

Leaders will need to optimize income in the fee-for-service delivery system In order to fund long-term investments in their physicians, IT systems, process redesign, clinical integration, and other improvements". N. Kaufman,2011 11 6

Barriers that Effect Speed of Change Local politics Physician resistance to change Slow movement of payors to adapt Payment methodologies to reward an emphasis on quality. 13 One Ochsner Network Center of Excellence Patient Health Management By providing patients with unparalleled access to clinical programs nationally recognized in quality, safety, and patient experience, in partnership with physicians and hospitals, we will grow regional, national, and international referrals By providing patients and physicians with unparalleled access to healthcare nationally recognized in quality, safety, and patient experience that controls medical cost below national trend, we will grow patient health management to care for over 250,000 Fee For Service Global Payments 7

Tightly Integrated Network with Coordinated Care is best approach for Managing Cost & Quality Post Acute Hospital Specialist Surgery Center Imaging Center PCP Specialist Community Hospital Patient Tertiary Hospital Urgent Care Center PCP Selection of Primary Care Physician Navigate the Healthcare System, Coordinate Care Aggressively Manage Chronic Conditions Proactive Outreach for Wellness Accurate Accounting of Cost, Quality & Utilization Ochsner Baton Rouge.. Journey to Care Coordination Three Roads to Travel 16 8

Pursuing Healthcare Value: What Care Model do you use? PCMH: This model frequently involves a care team working to manage all aspects of the patients' care and utilizing resources to maximize quality metrics, prevent readmissions, and improve quality of life. RN Health Coach: Team approach to manage populations in group treatment settings, comprehensive 1:1 visits both in the ambulatory or home setting. 17 What Model Did We Choose? The Care Coordination Model Define Scope: To improve the quality of care for the patients by: increasing the appropriate preventative screening rates, decreasing care performed outside our system, and increasing the star ratings for our HEDIS measures. We understand first hand that our model needed to be sustainable with a payment model that rewarded us for providing a higher quality of care. This model would act as a bridge towards the new era when payors and providers would all be aligned with payment incentives rewarding quality and no longer piecework units of care that might be considered meaningless 18 9

Coordinated Care: How Did We Build it? Perform Gap Analysis Learned more about our patients and the level of involvement in their care. Many were not managing their diseases when they were away from our care. Created a Shared Vision: PC Leads/Administration Practice Efficiency Review(every dept/every provider) Design Coordinated Care Model: Care Provider Team Manager 7 LPN s embedded into the practice Social Worker Access to Care Quality Service Financially Sustainable Model 19 Coordinated Care: How Did We Build it? Coordinated Care Pilot: Identified Physician Champion/Partner Global Process to serve All Patients/All Payors Performed pre-visit chart audits on patients (all payors) scheduled for 6 and 12 month follow ups/physical and focused on HCC and HEDIS service gaps Contacted all patients due for a 12 month physical. Education: Care Team Packets created and use as a vehicle to educate patient about their care provider team, our system, services and how to access care Hospital Readmission Process: Patient contacted and scheduled within 24/48 hours of admit Ongoing Tracking/Monitoring of our Progress External Benchmarking 20 10

Two Worlds of Healthcare Healthcare delivery system will not change overnight Physicians in critical specialties must be willing to participate and standardize clinical practices to minimize variation Pursuit of Value Initiatives: ORTHO/CARDIO Healthcare Systems must secure one EHR platform with hardwired point-of-care protocols EPIC Integrated throughout Organization 21 Criteria for Success Build sufficient primary care capacity using physician extenders as well Midlevel deployment, Practice Efficiency etc Develop physician champions to drive the process Primary Care Lead Physicians A programmatic approach to chronic diseases Accredited Diabetes Management Program, CHF Clinic, COPD 22 11

Criteria for Success Physicians who do not meet key cost and quality metrics must be sanctioned. Foster a culture of accountability amongst the physician group practice a. Patient Engagement: Tied to Compensation < 25%tile improvement class required b. OPE: Build internal relationships c. Quality Timely actionable data HEDIS Core Measures 23 Ochsner Baton Rouge (2012) 24 12

Baton Rouge Year over Year Comparison 25 Hierarchical Condition Category (HCC) Dashboard Closed HCC's Average HCC's Closed/Member 2012Baseline: CMS Accepted 2012 Baseline: HG2.22 and PHN 1.96 70,000 60,000 50,000 40,000 HG: Prior Year 62,701 48,232 40,670 41,535 30,043 62,703 50,198 53,988 2.50 2.00 1.50 HG: 2.18 PHN: 2.12 30,000 20,000 10,000 0 9,859 24,298 11,562 13,190 13,681 15,523 15,938 6,316 48 2,695 4,639 0 0 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct - 13+ 1.00 0.50 0.00 HUMANA GOLD PHN HG Prior Year HUMANA GOLD PHN Strategy: Members with OC PCP Office Visits YTD Average HCC's Closed/Region 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 2013 GOALALL: 95% 84% 82% 85% 86% 82% 85% 83% 84% 85% 83% 82% 83% 83% BAPTIST BATON ROUGE KENNER NORTHSHORE SOUTHSHORE Humana Gold PHN Goal Average Risk Score ST ANNE WESTBANK SYSTEM 2.50 2.30 2.10 1.90 1.70 1.50 2.50 2.30 2.10 HUMANA GOLD AVERAGE HCC COUNT 9/30/2013 10/18/2013 10/25/2013 11/1/2013 BATON ROUGE KENNER NORTHSHORE SOUTHSHORE ST ANNE WESTBANK SYSTEM PHN AVERAGE HCC COUNT 1.90 1.70 1.50 9/30/2013 10/18/2013 10/25/2013 11/1/2013 BATON ROUGE NORTHSHORE SOUTHSHORE WESTBANK SYSTEM * Rpt in SS = Included in Southshore Data 13

Re-Admissions(Oct 2012-Sept 2013) 25.0% 20.0% 15.0% 10.0% 5.0% ALL READMIT RATE READMIT THRU ER RATE ADMIT COUNT ALL READMITS READMIT THRU ER ALL READMIT RATE READMIT THRU ER RATE 66 13 12 19.7% 18.2% 77 11 11 14.3% 14.3% 72 7 7 9.7% 9.7% 74 17 17 23.0% 23.0% 80 15 14 18.8% 17.5% 72 12 12 16.7% 16.7% 74 15 13 20.3% 17.6% 62 5 5 8.1% 8.1% 63 8 8 12.7% 12.7% 50 5 4 10.0% 8.0% 77 9 6 11.7% 7.8% 65 10 10 15.4% 15.4% 27 Outside Provider Expense: $1.2M Top 25 Service Categories Full Year 2011 Full Year 2012 2011 Jan-July Actual 2012 Jan-July Actual 2013 Jan-July Actual Jan-July Trend (2011 to 2012) Jan-July Trend (2012 to 2013) IP HOSPITAL $12,847,938 $11,960,960 $7,808,642 $6,938,908 $5,359,795-11% -23% HOME HEALTH $3,753,118 $3,605,353 $2,308,066 $2,187,794 $1,304,454-5% -40% OP HOSPITAL $3,250,124 $3,210,539 $1,882,388 $1,928,906 $1,525,167 2% -21% SNF $2,449,477 $2,514,500 $1,487,226 $1,401,814 $1,504,412-6% 7% EMERGENCY DEPARTMENT $1,692,423 $1,757,106 $1,004,363 $1,002,333 $814,548 0% -19% DME $1,241,918 $1,091,783 $716,778 $679,271 $495,030-5% -27% HOSPITALIST $1,012,264 $940,642 $601,247 $569,549 $389,543-5% -32% KIDNEY CENTER $918,308 $1,119,089 $429,639 $585,895 $534,080 36% -9% PHYSICAL MEDICINE $873,980 $966,986 $495,770 $581,416 $455,317 17% -22% OPHTHALMOLOGY_RETINAL OPTOMETRY $770,956 $864,906 $442,014 $485,052 $408,341 10% -16% RADIATION ONCOLOGY $681,867 $652,084 $344,727 $474,338 $269,974 38% -43% AMBULANCE $705,947 $552,329 $432,130 $318,317 $286,195-26% -10% RADIOLOGY $630,952 $538,243 $358,209 $317,417 $285,527-11% -10% ORTHOPEDIC SURGERY $516,063 $557,543 $316,264 $308,454 $293,111-2% -5% DERMATOLOGY $514,422 $523,788 $290,137 $293,748 $247,465 1% -16% CARDIOLOGY $479,925 $487,811 $298,733 $287,130 $224,532-4% -22% NURSE ANESTHETIST $539,772 $516,652 $318,472 $304,184 $56,024-4% -82% UROLOGY $407,233 $407,601 $235,457 $250,920 $140,406 7% -44% LABORATORY $387,308 $395,576 $235,334 $206,603 $173,277-12% -16% GENERAL SURGERY $437,142 $287,202 $285,213 $165,998 $126,178-42% -24% ANESTHESIA $187,120 $214,168 $116,233 $129,153 $319,428 11% 147% THORACIC AND VASCULAR DISEASE $322,728 $287,003 $201,527 $153,144 $176,658-24% 15% HOSPITAL OTHER $294,817 $233,040 $234,974 $201,753 $88,884-14% -56% UNKNOWN $306,343 $321,043 $187,327 $154,258 $167,703-18% 9% INFUSION THERAPY $316,288 $281,783 $188,093 $183,988 $115,735-2% -37% $35,538,433 $34,287,730 $1,250,703 28 14

Quality Continuously improving and this past year Ochsner Medical Center was named to US News & World Report s Top 50 hospitals in 8 of 16 categories. Our six acute care community hospitals have led the region in Risk-Adjusted Mortality Index (RAMI) the last two years according to data from CareDiscovery. 29 OHS & Compare Group RAMI: FY 2012 2.0 OHS and Selected La. Hospitals: Risk Adjusted Mortality Index (RAMI) Adult, All Payor Discharges: FY 2012 from DOJ/LHIN Dataset Mortality Index Ordered Lowest (Best) to Highest (Worst) Thomson Reuters methodology change in 2012 does not exclude palliative care patients from risk-adjusted mort calculations. Mortality Index (RAMI) 1.8 1.6 1.4 1.2 2012 Mortality Index 1.0: Expected = Actual OHS 2012 Ave Index Competitor 2012 Ave Index For FY 2012, OHS average RAMI of 0.73 was approx. 37.3% lower (better) than the average RAMI of 1.16 for selected hospitals in Louisiana. Avg Competitor Index (FY2012 ): 1.16 1.0 0.8 At RAMI of 1 Actual Mortality Rate = Expected Mortality Rate 0.6 Avg OHS Index (FY 2012): 0.73 0.4 0.2 0.54 0.61 0.62 0.63 0.64 0.66 0.82 0.83 0.85 0.89 0.91 0.92 0.97 0.99 1.02 1.05 1.08 1.09 1.12 1.14 1.14 1.18 1.19 1.20 1.22 1.22 1.25 1.27 1.28 1.28 1.29 1.30 1.32 1.33 1.33 1.37 2.08 2.10 3.34 0.0 Data source: DOJ/LHIN dataset in CareDiscovery Risk Adjustment Methodology: Truven (fm. Thomson Reuters) Most recent data renormalization occurred in June 2012 Presented to Name Month, Day, Year 15

OHS & Compare Group ECRI: FY 2012 2.0 OHS and Selected La. Hospitals: Expected Complication Rate Index (ECRI) Adult, All Payor Discharges: FY 2012 from DOJ/LHIN Dateset Complication Index Ordered Lowest (Best) to Highest (Worst) Thomson Reuters methodology change in 2012 adds 17 Adverse Drug Events to riskadjusted comp calculations. Complications Index (ECRI) 1.8 1.6 1.4 1.2 1.0 2012 Complications Index 1.0: Expected = Actual OHS 2012 Ave Index Competitor 2012 Ave Index At ECRI of 1 Actual Complication Rate = Expected Complication Rate For FY 2012, OHS average ECRI of 0.88 was approx. 12.91% lower (better) than the average ECRI of 1.01 for selected hospitals in Louisiana. Avg Competitor Index (Q1-Q3 2012 ): 1.01 0.8 Avg OHS Index (Q1-Q3 2012): 0.88 0.6 0.4 0.2 0.0 0.61 0.71 0.81 0.81 0.83 0.83 0.84 0.88 0.88 0.92 0.93 0.93 0.94 0.96 0.96 0.97 0.97 0.98 1.01 1.01 1.02 1.03 1.04 1.04 1.04 1.05 1.08 1.09 1.10 1.11 1.12 1.13 1.19 1.19 1.22 1.23 1.30 1.39 1.60 Data source: DOJ/LHIN dataset in CareDiscovery Risk Adjustment Methodology: Truven (fm. Thomson Reuters) Most recent data renormalization occurred in June 2012 Presented to Name Month, Day, Year Medical Practice Baton Rouge Med Prac Overall (Benchmark Group: OHS 100+ Providers) Baton Rouge 94.0 100% 93.0 90% 92.0 80% 91.0 BR 2012 Perc Rank Goal 70% 90.0 60% 89.0 Q2-09 Q3-09 Q4-09 Q1-10 Q2-10 Q3-10 Q4-10 Q1-11 Q2-11 Q3-11 Q4-11 Q1-12 Q2-12 Q3-12 Q4-12 Q1-13 Q2-13 Q3-13 Raw Score 90.5 90.5 91.8 91.4 91.8 92.0 92.4 93.3 92.5 92.1 92.2 92.8 92.3 92.2 92.0 92.3 91.9 91.4 Perc Rank 68% 66% 88% 78% 84% 87% 87% 91% 94% 95% 96% 99% 94% 89% 87% 95% 83% 60% 50% Top Priority Question (Q2-12) Our sensitivity to patients needs Presented to Name Month, Day, Year Standard questions only. 16

Criteria for Success Infrastructure must be built to monitor, manage and report outcomes. Care Coordination Team 33 Criteria for Success Hospital Based Physicians (Hospitalists, intensivists, etc.) must be trained in the latest care delivery techniques and evaluated based on cost, quality, and service metrics. Telemedicine: Tele-Stroke, E-ICU and Improved Critical Care Model 34 17

It is our belief that in addition to operational efficiency, improved quality and lowering costs.. We have driven Cultural Transformation Commitment Degree of organizational Support Awareness Understanding Acceptance Yields Results Collaboration Transparency of Results Meetings with PC Leads and Staff Time 35 Success: Focus on Focusing: Laser Focus Accurate, Actionable Data Breaking Down the Silo s through: Collaboration Communication Commitment Eliminated Variation Strengthened the Physician/Administrative Dyad Relationships and Leadership Celebrate success Our Secret Sauce 36 18

Questions? 37 Learn More About Ochsner Ochsner Health System: http://www.ochsner.org History of Ochsner: http://www.ochsner.org/video/detail/history_of_ochsner Katrina: http://www.ochsner.org/video/detail/then_now_proud_moments_since_katrina MyOchsner Patient Portal: https://my.ochsner.org/prd MyOchsner 38 19