Using Data for Proactive Patient Population Management Kate Lichtenberg, DO, MPH, FAAFP October 16, 2013 Topics Review population based care Understand the use of registries Harnessing the power of EHRs Strategies for filling in the data gaps Payer solutions Tying it all together 2 1
Challenges in the US Health Care System U.S. ranks last or next to last in key areas of a high performing health care system 1 : Quality Access Efficiency Equity Healthy lives 1 The Commonwealth Fund June 2010 Structural Challenges Fragmented system with lack of primary care Lack of evidence based care driving variation in quality & safety Misalignment of incentives Transaction based system Lack of transparency Limited focus on quality 3 The Focus on Primary Care Primary care physicians are best equipped to provide proactive, whole patient care that can move us towards a coordinated system built around the needs of the individual patient. Care coordinated by a primary care physician is associated with better outcomes for individuals with chronic diseases and disease management. 4 2
A Primary Care Patient-Centered Approach Increased patient participation in medical decisionmaking Increased patient success with shared care plans Coordination of preventive, acute, and chronic needs The hallmarks of a patient-centered care model Increased physician satisfaction with medical practice Cost-efficient management of chronic and complex conditions Ability to foster valuebased referrals 5 Population Based Care-The Basics Panels of patients Health plan members Patients associated with a physician, practice, or delivery system Distinct from the public health perspective of the population 6 3
Who to Target? Disease Specific Prevention Specific Elderly 7 A Tale of Two Circles The entire population Sub-population needing Prevention of health services Prevention of problems and promotion of health From Lucy Johns, Population Medicine in Managed Care 8 4
Predictive Modeling Claim activity Pharmacy Physician/Hospital/Other ancillary Laboratory activity Other sources? 9 Why Target? Over-utilization Under-utilization Measure and compare how well patients and populations are being served 10 5
Physician Resistance Fear of under-mining physician-patient relationship Physicians will not adequately advocate for individual patient needs I treat patients, not populations! 11 Population Based AND Patient Centered Adds another dimension Individuals benefit from the guidelines developed for the populations to which they belong Must consider patient s own values Right care, right time, right place, right price 12 6
Registries Enable the provider to ensure that all their patients are getting proper care Track the progress of high-risk patients Identify the need for follow-up services Increase quality of care and improve patient outcomes Empower patients to take an active role in their treatment Coordinate care and identify gaps Incorporate consensus guidelines for disease management 13 Paper Registries 14 7
Electronic Registries 15 Harnessing the Power of EHRs Assess your EHR s capabilities Epic Cerner AllScripts Control your data Don t let the data control you 16 8
Filling In the Gaps Missouri Health Connection Secure health information network Providing services to more than 7000 physicians, 62 hospitals, and 350 clinics in Missouri and neighboring states Can connect with all certified EHR systems 17 Anthem s Solution Patient Centered Primary Care Initiative Already occurring in St. Louis Metro area and Southwest Missouri Provides an additional source of meaningful data to augment proactive care 18 9
A Solution to Address the Challenges With the Current System Fragmented Health System Lack of Evidence Based Care Current Challenges Care delivery is disjointed and fragmented across various stakeholders Care coordination is siloed, with disease-focused care Patient Centered Solution Care continuum is collaborative amongst all stakeholders Focus on clinical integration and safe and effective care Misalignment of Incentives Transactional Operations Lack of Transparency Limited Focus on Quality Providers and consumers not aligned towards value Transaction based business operations focused on procurement and financing Disparate clinical and administrative platforms Focus of provider strategies on rate, value, and market share Incentives aligned around outcomes and quality to address affordability Low cost administration with enhanced consumer experience Access to consistent longitudinal clinical information across care continuum Leverage performance risk to collaborate on care and service quality 19 PC2 Framework Meets Providers Where They Are We meet providers where they are and support them to transform, driving transformation and optimal performance market wide Stage 1: Smart first steps Low Capabilities Limited knowledge and experience with population health management Limited availability of resources and staffing to support CM and coordination activities Limited analytics Minimal monitoring of outcomes Shared savings Small Physician practices & PCMHs Stage 2: Align capabilities & stakeholders Provider Capabilities Access to systems / data to support population heath management Shared resources for CM and coordination activities Knowledge of analytics and measures to monitor outcomes Willingness to participate in alternative risk arrangements Large physician groups, PCMH, ACOs Stage 3: Achieve sustainable model High Capabilities Stage 1 Stage 2 Stage 3 Automated processes and systems to support population health management Fully dedicated CM resources within the practice Actively utilize analytics to focus on high-risk chronic care patients and monitor outcomes Knowledge of and/or participating in risk based fee arrangements Advanced PCMH, ACOs 20 10
The Patient-Centered Primary Care Solution To allow practices to effectively transform to a patient-centered model, the following pillars are fundamental: Pillar 1 Pillar 2 Pillar 3 Pillar 4 Payment Redesign Better Access to Care Care Management and Coordination Exchange of Meaningful Use of Information Patient-Centered Primary Care 21 Pillar 1: Payment Redesign Physicians will be incentivized to provide quality and cost effective care through aligned reimbursement. Payment Redesign Per Member Per Month (PMPM) Clinical Coordination Payments*: Targeted PMPM payments pay practices fixed fees for important clinical interventions that occur outside of a patient visit. These payments provide physicians with a predictable cash flow that lets them invest to improve their practice. Shared Savings: The Patient Centered Primary Care Program introduces a shared savings incentive program that allows providers to earn a portion of the savings that accrue when they provide patient centered care as long as they meet the programs quality measures. The shared savings payments reward providers for improving the health of their patients and provide compensation for non-visit based clinical interventions, such as care planning, that have a positive impact on patient outcomes and cost. * Some exceptions apply 22 11
Pillar 2: Better Access to Care Better Access to Care What it means: Being available Access to patient history 24/7 Using Web-based technology and e-visits Leveraging retail clinics or nurse practitioners How we help providers offer better access: Providing information on ER alternatives Offering access to the MMHPlus Supporting web-based visits 23 Pillar 3: Care Management and Coordination Care Management and Coordination The provider toolkit will include a comprehensive set of resources to assist in care management and other transformation activities. Our new internal roles we have created will help practices with identifying high-risk patients, and assist in creating the enhanced care plans for those patients. Combined, these resources will help create successful care plans for patients. 24 12
Pillar 4: Exchange of Information Exchange of Meaningful Use of Information We will provide actionable analytic reports on: Avoidable ER use Gaps in care Attributed high-risk/high-cost members Specialty referral management We provide interpretive guidance Provides practices with the data to improve the health status of their patients and reduce costs associated with avoidable ER, readmissions, etc. 25 Attribution: What is it and How Does it Work? Attribution is the foundation for clinical coordination PMPM payments as well as shared savings calculations and payments. It is the method for identifying the defined patient population. There are two processes used for attribution depending on the product type Open Access Products (PPO) Attribution is based on historical claims data incurred in a 24-month period Products Requiring PCP Selection Attribution is based on covered individuals selection during a 12-month period 26 13
Active Report Details information about the provider s attributed members, including information on each member s attribution method and attribution duration. Details include: Demographic(s) Attribution method Attribution duration Primary PCP s visit count Total PCP (primary + other) visit counts Total specialist count Description Report with members demographics and details around attribution including leakage visits. Report frequency Quarterly with daily eligibility-based adjustments 27 Hot Spotter Report Identifies attributed patients who may benefit from a care plan. The report generally targets attributed members with a recent inpatient admission as well as those with chronic diseases. Details include: Demographic(s) Primary risk drivers (determinants of selection) Prospective risk score Summary of gaps in care Diagnostic groupings Recent information on admissions and emergency room visits. Cost summary (dollars related to inpatient, outpatient, medical and Rx). Description Detailed report that identifies highest risk members with member demographics, ER utilization, Care Management engagement and cost of care. Risk is determined based on variety of factors including readmission and chronic conditions. Report Frequency Daily for readmission risk Monthly for chronic risk Report Color Status Code Color-coded by Prospective Risk Score Change 10%-20% in yellow colored cell 20.01%+ in red colored cell 28 14
Inpatient Authorization Member List Identifies all attributed members who have been authorized for an inpatient admission. Attributed members remain on the report from the time of admission was authorized through 7 days post-discharge. Detail includes: Demographics Predictive information on likelihood for readmission Primary risk drivers (determinants of selection) Admission detail (hospital name, admission date, admitting diagnosis, etc.) Description Detailed report with member demographics, inpatient authorization details, readmission risk, utilization metrics and care management engagement. Report Frequency Daily 29 How the Inpatient Authorization Report Helps Patients: Sam s Story Jane reviews the Anthem inpatient authorization report and notices that Sam is on the list. Sam is a long time patient who the practice knows has documented stable congestive heart failure. Jane makes a phone call and reaches Sam s wife who tells Jane the reason for the hospitalization- Sam s sudden and acute shortness of breath on the weekend leading to an ER visit. He is scheduled for discharge today. Jane makes an appointment for Sam for the next day and documents the information. At the huddle the next day, she is able to give the physician this information in anticipation of the visit. 30 15
How the Care Opportunity Report Helps Patients: Jim s Story Jane reviews the Anthem care opportunity report and is surprised to see that Jim is overdue for his A1C. He is a long time patient and has a history of routine visits for his Type II Diabetes. Jane reviews Jim s chart and sees that it has been over a year since he has been in. When she contacts him, she finds out that his daughter has moved out of state and that he really misses her. She always helped him in remembering to visit the doctor. They make a visit for the next week, scheduling his labs for before the visit. He is very appreciative of the reminder. At the huddle the next week, she is able to give the physician this information in anticipation of the visit, including the lab results. 31 Member Medical History + (MMH+) Web-based service that provides patients personal health information to clinicians Information available on MMH+ Physicians seen by the patient Covered individual demographics Eligibility history Patient diagnoses Procedures performed Medications filled by the patient Care alerts Lab results for the patient (if performed at certain national labs) Utilization management and case management for patient 32 16
Member Medical History Plus (MMH+) The following information about a patient is available from MMH+: Physicians seen by this patient Member demographics Eligibility history Diagnoses this patient has had Procedures performed on this patient Medications filled by this patient Care Alerts Lab results for this patient (currently LabCorp and Quest) Utilization Management, Care Management and Disease Management cases. 33 MMH+ Professional Claims 34 17
MMH+ Facility Claims 35 MMH+ Lab Results 36 18
MMH+ Medical Management - UM 37 MMH+ Patient Summary 38 19
Patient Centered Care Payment Design: Three Components Member attribution assigns a member to a provider based on either member selection or through derivation off of member s historical visit patterns PMPM payment for non-visit Care coordination support, including: Responding to patient e-mails and phone calls Development of care coordination plans such as a care coordination plan for a child with severe asthma Follow-up care plan for a patient recently discharged from the hospital Care coordination fees Member attribution Shared savings represent the real opportunity for increased revenue. To be eligible, providers must first achieve a threshold level of quality based on physician quality, service, and performance criteria. Once that threshold is met, they can qualify to receive 20 percent to 30 percent of the savings achieved through this program. Shared savings 39 Clinical Coordination Reimbursement For Illustrative Purposes Only Member #1 Member #2 Healthy 2 year old Receives an annual preventive well-child visit Clinical Coordination * : $1.50 PMPM * 0.5 = $0.75 Middle-aged female (~55) with diabetes Visits PCP semiannually to review care plan and monitor HbA1c level Clinical Coordination * : $1.50 PMPM * 2.0 = $3.00 Member 1 risk score: 0.5 Member 2 risk score: 2.0 Lower risk score Higher risk score *PMPM base rate may vary. 40 20
Shared Savings Payments Shared savings payments provide the incentives for PCPs to manage the overall healthcare costs for their defined patient population How it works: Medical Cost Targets are established by reviewing historical expenses and trending forward Member costs incurred during a measurement period are compared to the medical cost targets and the provider group shares in any savings Quality is crucial: providers must meet a quality threshold to qualify for shared savings payments. The better the quality scores, the higher the percentage of the shared savings the providers earn. 41 Practice Transformation Providers start (or continue) the transformation to a patient centered care model including: Enhancing availability Embrace alternate forms of access to ensure that the patient receives the right care at the right time and in the right setting Establishing internal infrastructure to coordinate care Becoming an active participant in care management Using a disease registry to manage chronic patients Using generic Rx substitutes when clinically appropriate Meeting appropriate performance on nationally-endorsed quality measures 42 21
Transformation Milestones #1: Establish internal infrastructure to coordinate care #2: Establish process to review and utilize Anthem reports and MMHPlus for population health management and high risk patient stratification #3: Establish sustainable process for shared care planning including self management support/goal setting/action planning #4: Establish and maintain Population Health Registry and Anthem reports for patient outreach, closing care gaps, and managing prevention and chronic disease needs of patients. #5: Maximize e-health record and/or available health information for evidence based care delivery and relevant Clinical Decision support #6: Transition to a culture of patientcentered care #7: Provision of enhanced access for patients #8: Establish external processes and infrastructure to achieve coordination of care with the medical neighborhood and community #9: Achieve improved clinical, utilization and affordability outcomes #10: Strongly recommend Level III NCQA PCMH Recognition 43 New Roles Created to Support Transformation Community Collaboration Manager Supports the Patient-Centered Care Consultant by helping to analyze reports and data to inform decision-making around practice support needs. By creating a practice Transformation Action Plan, the Community Collaboration Manager can suggest interventions based on practice-level data. Also helps create relevant Learning Collaborative content. Patient-Centered Care Consultant Helps practices access and interpret Anthem reports; helps them use those reports to design interventions aimed at improving outcomes. Works with providers to test and refine workflows; guides expansion of interventions to additional patient populations. Connects providers to programmatic and community tools and resources. Physician Director Responsible for developing and leading the strategy for the Patient-Centered Primary Care Program. Lead point of contact for practices to address clinical and operational elements for the program. Supports physicians in practice transformation including discussions and onsite visits Provider Clinical Liaison Helps practices develop care coordination and care management skills. Helps interpret clinical reports and identify patients who can benefit from a care plan. Assists in care plan creation. Serves as a subject matter expert on internal CM programs. Helps manage patients with more complex needs via available Anthem programs. Promotes coordination between the PCP and Anthem programs. Contract Advisor Supports practice operations, implementation and ongoing maintenance of the Program. Organizes local meetings and Learning Collaboratives for the practices. 44 22
Roles Inside Your Practice Role Provider Champion Practice Manager Care Coordinator Transformation Team Members Description The Provider Champion is a physician, or in some cases an Advanced Practice Nurse, in a leadership position in your practice who is the leader of your practice s patient-centered care approach. This individual has the authority to support and influence transformation to patient-centered care, and supports the needed activities, provides resources and communicates to other physicians about the Program. The Practice Manager is the individual in your practice who manages the day to day activities in a primary care office. The Care Coordinator is the individual in your practice who facilitates the care coordination and care plan creation for patients. The Transformation Team Members are those individuals in your practice who participate in Program activities focused on improving patient care using recognized quality improvement methodology. Ideally this group of individuals should include a representative from each area within your office (for example: front office, back office, clinical, billing, etc.). 45 Practice Support Dedicated Anthem resources will provide hands-on assistance to practices. Help will include: Targeted support in learning to use the new data, reports and tools Suggestions on appropriate toolkits Guidance on getting the most out of available Anthem resources We will meet providers where they are in the process and help them move forward with their transformation activities. 46 23
Tying it All Together Medical Neighborhoods All part of the same system? State HIE s Bordering states like Illinois? Time, energy, and money needed to make and incorporate changes Still feels like we are patching things together 47 Going from. 48 24
Going to. 49 Questions 50 25