Aligning value incentives in program design IOM Roundtable

Aligning value incentives in program design IOM Roundtable on Value & Science-Driven Health Care

March 14, 2012

Rodney C. Armstead, MD FACP

Optum Executive, Collaborative Care

IOM_Armstead 03142012 Final

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Provider-Led Care Models

Risk and Accountability Collaborative

care

Improve financial

management

Lower cost of care

Compliance and reporting

Improve quality of care,

outcomes

Understand population

health

Manage patient and population

risk

Patient engagement

Providers are at the Epicenter of New Models of Care

Science-Driven Clinical

Decisions

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Care Provider Payment Models

Care Provider Practice Models

Cumulative addressable market

Integrated health system- focus

Optimizing total population health

Global market risk model

Professional services risk model

Episode of illness payment

Bundled services payment

Fee-for-service

Fully-integrated delivery systems

Multi-specialty group

practices

Physician hospital

organizations

Independent practice

associations

Market Change Will Take Many Forms… Community by Community

New value creation for existing solutions; creation of new markets

Virtual community networks

Sole practitioners


Goals of the new model

• Macro-level

– Improve the consumer experience

– Improve the overall health of the population

– Improve individual health outcomes

– Decrease cost

• Micro-level

– Seamless connectivity that delivers clinical information/value based options for the provider and patient at the point of care—optimizes science driven decisions

– Transformational consumer & provider engagement

– Sustainable solutions addressing health literacy


What does improved quality & cost-effectiveness look like?

• Improved quality

– Sustained & high performance as measured by quality of care and service outcomes, i.e., HEDIS, STAR ratings and other measures exceeding national benchmarks

– Sustained & high consumer & provider satisfaction

– Sustained populations health measures at or above 90th percentile

– Mitigation of gaps in health literacy

– Right care, right place, right time

• Cost-effectiveness

– Zero-extremely low medical cost trend YOY that is sustainable

– Extremely cost effective delivery systems that will result in competitive premiums for individual, private and public payers

– Consistent throughout: provider payment aligned with performance/outcomes

– Value based efficiency metrics


Keys to success

• Interconnectivity/inoperability of a network of providers

• HIT infrastructure: eMR, data warehouse, point of care decision tools, shared flow of information across care settings and the ability to populate the measures that prove that value was achieved

• Consensus standards by which performance is measured with complete transparency

• Alignment of measures between CMS, States and Commercial purchasers given the fact that most physicians are multi-payer

• Regardless of the clinical model: a physician-led culture is essential/critical


Specialist (FFS & High Quality)

Collaborative Practice Features

SNF & Transition

Facilities

Specialist (i.e., Capitated

& High Quality)

Hospital E.R

Hospitalist

Actively managed care

coordination by a

Clinical Team of

physicians and nurses

PA NP

MD

NP MD

PA

NP

MD

Delivery System Design (Practice Model)

• Primary Care Practice: contracted with aligned payment | supported with data and clinical support network |

close integration and coordination

• Care Center: clinic and infrastructure focused on chronic and complex patients and after hours support

• Hospital and Hospitalist: contracted and supported with embedded Transition Coach

• Specialists: right sized network, prioritized based on quality (performance + patient satisfaction) and

economic criteria

PA

NP

MD

PA

Primary Care Providers

Employed

Contracted

NP

PA

MD

PA


Earning loyalty and trust though an innovative, breakthrough service experience, connecting our patients and their physicians

Collaborative Technology

InformAction

People that Care to Act

Incentives for Improving Health

Administration Assistance

Billing/Reimbursement

Claims Processing

Patient Scheduling

Prescription Refills

Clinical Community

Physicians/Clinicians

Case Managers

Health Coaches

Home Care/ Remote Monitoring

Linking Information

Health and Drug History

Wellness Education

Transportation

Life Transitions/ Social Assistance

Care Center

Delivery System Design (Service Model)


Delivering Care and Services to Patients

Preventative Care

Telehealth| Primary Care

Retail Clinics | Specialists

Senior/Community Centers | E-visits

| Mobility Assistance

Remote Monitoring | Infusion Therapy

Transition Services | House Calls

Institutional Patient Mgmt²

Chronically-Ill Mgmt³ | Admission To Home

Palliative and Hospice Care5

Ambulatory | Emergency Room | Urgent Care

Connected, intelligent and aligned health

communities meeting each patient’s

needs

2. Skilled Nursing; 3. Nurse Practitioner Home Visits; 4. 12-18 Months to Live; 5. <6 Months to Live

Local Integrated

Delivery Systems

Coordinated

Care at Home

Customized care solutions delivered

before or after a medical event

Interconnectivity Interoperability


Practical Application of Coordinated IPAs

• Care system where doctors, medical information, care plans and medication history all connect together.

• Providing quality medical care that is safe, effective, efficient, timely, personalized, and equitable for its members.

• Ability to have a multi-payer platform

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IPA Technology Integration

Physicians

Urgent Care

Home Health

Care Teams

Physician Assistants

Nurse Practitioners

Electronic Medical Record

• Tasking • Referral integration

• E-Rx

Digital Imaging

• Radiology • Integrated into EMR

• Cardiology

External Connections

• Quest Lab • Referrals – specialists

• Pharmacies

Web-based Self-Service

• Appointment scheduling • E-visits

• Problems • Portable medical record

• Rx renewal • Results

• Vitals • Advanced directive

Custom Clinic Tools

• Kiosk check-in

• Skype- like customer service Kiosk

• Patient education

• Patient medical profile (wrapper) for triage

Patient Notifications

Automated phone calls and email

• Appointment reminders

• Rx notifications

• Orders/results notifications


Practical Application of Coordinated Post Acute Care

• Providing innovative, provider-driven, patient centric healthcare solutions designed for high risk, medically complex populations

• Delivering the right care, to the right patients, at the right time, resulting in improved quality and lower health care costs

• Proven success and cost savings

– Impact on Acute Admits

– ER Readmission Rates

– Cost of End of Life Care


High Risk Dual SNP Members – Acute Admits/1,000 Comparison

1,6231,690

1,4651,567

1,4031,529

1,975

1,608

633715

633 677

354

630502

593 563

-

500

1,000

1,500

2,000

2,500

Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 7 Month

Avg.

Combined

Next 12

Months

Control Group INSPIRIS Treatment Group

Control Group Treatment Group


High Risk Medicare Advantage Members Medication Management

Pre Program Program

2.0

6.0

11.5

2.7

4.3

5.6

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

3 or Less 4 to 8 9 or More


High Risk Medicare Advantage Members End of Life Care

Enrolled High Risk (non-enrolled) Non-enrolled

End of Life PMPM Cost

$3,869

$4,129 $4,176 $4,689

$5,465

$6,427

$6,930 $7,424

$7,924

$8,691

$10,076

$11,799

$3,717

$4,154 $4,723

$5,550

$6,900

$9,468

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000

Month 6 Month 5 Month 4 Month 3 Month 2 Month 1


High Risk Age, Blind & Disabled Medicaid Members

• Strong reduction in acute admissions/K compared to baseline

• Reducing from 2,400 Admits/K to an average of 1,090/K

• Average 30 day readmission rate dropped to 23% from 32.7%


Transitions Reduction in Readmissions

Medicare Advantage Members

Average Medicare Advantage Plan

With Transition

Program

21.0% 13.9%


Sub-Acute SNF Transitions – Medicare Advantage Members Skilled Length of Stay Improvement

17.50 17.50 17.50 17.50 17.50

14.0014.41 14.34 14.13 13.98

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

18.00

20.00

2006 2007 2008 2009 2010

Baseline ALSO Program ALOS

Reduction of 2.97 to 3.52 Days Saved


Barriers to future success

• Reconciling the confusing landscape of competing performance measures across the system

• Sub-optimal HIT inter-connectivity and inter-operability

• Adequate capital needed for practice transformation

• Gap between fee-for-service and value base contracting that is needed to fully drive change

Rodney C. Armstead, MD FACP Optum 77 Water Street, 14th floor New York, New York 10005 212-898-8498 [email protected]

Documents

Aligning value incentives in program design IOM Roundtable