Update on Population Health Structure, Platform & Analytics March 2016 Chuck Sawyers Vice President of Finance Nationally ranked integrated healthcare delivery system 501 c 3 not-for-profit $1.5 billion in annual revenue Headquartered in Roanoke 12,000 employees 1,000 employed providers 7 hospitals Urgent care facilities, home health agencies, retail pharmacies, wellness center, patient transportation Children s Hospital Jefferson College of Health Sciences VTC School of Medicine & Research Institute 1
Carilion Clinic Integrated delivery system with multiple access points 3 Roadmap for Discussion 1) Organizational Transition 2) Funding 3) Support Structure 4) Results 5) Moving Forward 2
Background Strong primary care focus since 1996 Purchased large primary care practice Implemented group-wide EMR in 2000 Logician/Centricity Created internal scorecards in 2005 reviewing quality of care by provider Diabetes perfect care Hypertension control Background 2007 - Carilion Health System became Carilion Clinic Increased physician leadership and a focus on being an Accountable Care Organization 2008 - implemented EPIC system-wide 2010 - opened a medical school with Virginia Tech 2013 - entered MSSP program 3
Clinic Transition Goals Broaden the number of specialties working at Carilion Standardize our primary care model (PCMH) Fully utilize EMR to enhance communication Strengthen our patient-centered approach Funding Sources Initial: Meaningful Use Incentive PMPM for Care Management Care Coordinator Visits 4
Funding (cont d) Current: Pay for Performance Opportunities Medicare Advantage Commercial Shared Savings CMS billing options Transitions of Care (TCM) Annual Medicare Wellness Chronic Care Management Funding (cont d) Unsuccessful (so far): Owned health plans Medicare Advantage Medicaid MSSP Good quality scores but did not meet 2% shared savings threshold 5
Ambulatory Programs Participation Payment Formats Medicare Advantage Humana quality metrics, shared savings & PAFs United Healthcare quality metrics, shared savings (after quality gate), incentive payments for PCP visits, PAFs Commercial Aetna gain/risk share after quality gate Anthem quality metrics & shared savings Optima (Sentara) quality metrics CMS Medicare Shared Savings Program (MSSP) Quality reporting will govern impact of Value Based Modifier on full group Meaningful Use incentive to penalty 2017 - Merit Based Incentive Payment System Structure to Address Opportunities Pay for Performance Team (2014 weekly mtgs) Comprised of Senior Medical Director, SVP-ACS, Director of Contracting, Manager of Performance & Quality Imp & Project Consultant Scope: narrowing focus (100+ metrics), tracking progress, suggest changes, work with payers & IT Created central P4P group (17 person) Added Central Care Coordination group (5 person) In addition to Care Coordinators in PCMHs 6
Central P4P Team Comprised of Project Consultants, RN/LPNs, Certified Medical Assistants, Medical Office Associates Combining payer data with EMR report data, then performing chart review for non-discrete data Role is to facilitate closing gaps in care (labs, screenings, office visits, etc) Scheduling visits and communicating with care team for upcoming appointments Tracking of work is currently outside of EMR, currently in Excel, but working with IT to have all tracked in EMR for 2016 Silos & Synergies Discovered other groups working in the system on similar work Focused on specific P4P metrics Developing protocols and processes Somewhat in silos Opportunities existed for working together Proposal approved to link these efforts under one Accountable Care umbrella 7
New Approach: Accountable Care Transition Team AQC Care Transitions Group SNF Collaboration Taskforce Extensivist Clinic CCMH Central Care Coordination Employee Health Plan Accountable Care Transition Team Tele-Health ED Case Management CHF Transitional Visits Advance Care Planning Pay 4 Performance Team Goals of ACT Team Greater understanding of all activities around Carilion Clinic Find synergies to be more effective together Prioritize where to put resources Enhance communication & gain input Develop & recommend new protocols Review pilots and recommend changes and expansion to new sites 8
Payer Data Issues Discovered issues with the payer provided reports very early in engagement with these programs Provider attribution (provider rosters, assigned vs. attributed, veterans going to the VA) Lab value data not received or recorded Multi-year metrics (breast cancer screen, colorectal cancer screening) Interventions for data Continual, consistent engagement with payers on attribution Data feed set up with payers for lab data Supplemental data provided through PAF process, as well as providing internal reports quarterly to one of the payer partners CONSTANT COMMUNICATION WITH PAYERS!! Analytics Opportunities After much frustration with payer data limitations we are now requesting raw claims data to complement our clinical (EPIC) information Created EDW to assist in gathering claims data and reports to drive performance Pharmacy dispense data (medication adherence, generic dispensing) System and non-system utilization (ER and hospital) 9
Using Data to Our Advantage Need to align incentives Compensation tied to P4P performance Stay focused on best interests of the patient Develop user-friendly reports/scorecards to inform physicians of their performance compared with peers/benchmarks Working with provider, practice, and care coordination leadership on developing the most effective workflows to impact performance Department of Family & Community Medicine Scorecard 10
Results Medical Homes with a multi-year focus on metrics Alignment of compensation with scorecard metrics Alignment of scorecard metrics to match pay for performance metrics Utilization of scorecard metrics across ALL departments at Carilion This work has shown results 2015 Payments Achieved Payer Potential Success Anthem $3.77M $3.69M United 3.52M 2.26M Humana.97M.20M Aetna.41M.34M CMS.29M.29M Optima.14M.04M Total $9.11M $6.83M 11
Annual Trends Example of Metrics Results Table 3.1 Impact on Chronic Disease Management Carilion Clinic Medical Home Performance by Measure and Reporting Period 2009-2014 CLINICAL MEASURE BASELINE Year Prior to Transition YR 1 YR 4 HEDIS National Mean 2013 % CHANGE Baseline to YR 4 DM: HbA1c Test Frequency Percentage of diabetics 18-75 years of age with HbA1c test in the past six months DM: HbA1c Value Percentage of diabetics 18-75 years of age with HbA1c control <8.0% DM: Blood Pressure Control Percentage of diabetics 18-75 years of age with blood pressure <140/90 mm Hg DM: LDL Control Percentage of diabetics 18-75 years of age with LDL C control <100 mg/dl HTN: Blood Pressure Control Percentage of hypertensives 18-85 years of age with blood pressure <140/90 mm Hg 72.2% 91.3% 91.5% 87.7% 26.7% 79.2% 78.8% 74.4% 55.9% -6.1% 69.8% 71.9% 67.9% 59.3% -2.9% 50.3% 57.1% 59.4% 43.0% 18.1% 62.3% 66.4% 72.4% 57.6% 16.2% Asthma: Controller Medications Percentage of severe persistents 5-64 years of age with controller meds prescribed (Insufficient Sample Size) 75.9% 92.5% 90.7% 21.9% Data Source: Clinical Informatics and Analytics. Monthly Ambulatory Measures Reports. 2009-2014. Clinical Measures: NCQA. State of Health Care Quality, 2012; approved for use by Ambulatory Quality Committee. Baseline: Entries are means for all nine sites; snapshot taken 12 months prior to model transition. Reporting Periods: Do not equate to calendar years because of staggered site transition starting dates. HEDIS National Mean: NCQA, State of Health Care Quality, 2013; weighted per payment contribution within the nine sites; method approved by NCQA in 2010. % Change: The percent change from baseline to YR 4 result. 12
Number of ED Visits Number of Inpatient Admissions 3/1/2016 Medical Home Impact on ED Utilization (All Patients with 1 or more ED Visits before Medical Home Engagement) 250 200 229 33% n = 139 150 153 55% 100 103 50 0 One Year Before Medical Home Engagement Changes in ED Utilization After Medical Home Engagement (Year 1 vs. Baseline) # Pt's Decreased Utilization 93 66.9% # Pt's Increased Utilization 28 20.1% # Pt's No Change 18 12.9% Number of Patients 139 One Year After Medical Home Engagement Two Years After Medical Home Engagement Changes in ED Utilization After Medical Home Engagement (Year 2 vs. Baseline) # Pt's Decreased Utilization 97 69.8% # Pt's Increased Utilization 13 9.4% # Pt's No Change 29 20.9% Number of Patients 139 Medical Home Impact on Inpatient Utilization 250 (All Patients with 1 or more IP Admissions before Medical Home Engagement) 200 201 n = 130 150 43% 100 115 57% 86 50 0 One Year Before Medical Home Engagement One Year After Medical Home Engagement Two Years After Medical Home Engagement Changes in IP Utilization After Medical Home Engagement (Year 1 vs. Baseline) # Pt's Decreased Utilization 91 70.0% # Pt's Increased Utilization 18 13.8% # Pt's No Change 21 16.2% Number of Patients 130 Changes in IP Utilization After Medical Home Engagement (Year 2 vs. Baseline) # Pt's Decreased Utilization 95 73.1% # Pt's Increased Utilization 13 10.0% # Pt's No Change 22 16.9% Number of Patients 130 13
Next Steps Better understanding of utilization & spend Aggregating payer data to create a single report for a provider Employing a more robust care management system Better communication across all providers Better care plan documentation Consideration of additional partnerships and value/risk contracts Questions? 14