Doing Care Differently: The Journey to a Healthier Kentucky Innovate, Accelerate, Collaborate 2014 Howard L. Bost Memorial Health Policy Forum September

Doing Care Differently:The Journey to a Healthier Kentucky

Innovate, Accelerate, Collaborate

2014 Howard L. Bost Memorial Health Policy ForumSeptember 16, 2013

“Health is a state of complete physical, mental and social well-being and not merely

the absence of disease or infirmity.”

Health Impact Pyramid (CDC)Factors that Affect Health

Source: Georgia Department of Public Health; Centers for Disease Control and Prevention

3Copyright © 2014 FTI Consulting, Inc.

The Institute for Healthcare Improvement (IHI)The Triple Aim

U.S. health care system is the most costly in the world

Yet, we get the worst outcomes of nearly any industrialized country, even when adjusting for age and income

And, Kentucky is among the lowest U.S. states for outcomes, according to the America’s Health Rankings

Source: Georgia Department of Public Health

http://www.ihi.org/Engage/Initiatives/TripleAim/pages/default.aspx

Population Health

Per Capita CostExperience of Care


The Healthcare Landscape

“Digital Health feels like the PC industry in the early ’80′s.”

John Sculley – Former Apple and PepsiCo CEO

“I think the extreme complexity of medicine has become more than an individual clinician can handle. But not more than teams of clinicians can handle.”

Atul Gawande – Surgeon, Author, Journalist

“I don’t blame anybody – they’re just doing what makes sense and we have to change what makes sense.”

Don Berwick – Former CMS Administrator


Perspectives: Healthcare is a different industry than it used to be


The U.S. health market requires greater flexibility and insight than ever before. Leaders increasingly need expert advice to make sound decisions in today’s climate.

Regulatory Environment

Aging Population

Evolving Payment Models

State Budget Crises

Unprecedented

Environmental Change

Consumerism

Comparative Transparency

Workforce Challenges

Emerging Technologies

Quest for Value

The Market Is Complex And Evolving



Demographics Healthcare Reform

Population GrowthPopulation AgeingChronic Conditions

Economic Pressure

GovernmentsEmployersMarket Competition

PPACA (US)Other global reform (e.g., GER)ARRA, HITECH for EHR

Aggregation, Storage and AnalyticsPooling/Open DataData Center Capacity

TelemedicineWireless SensorsRemote Patient MonitoringApps/Social Media

GenomicsTargeted TherapeuticsPersonalized TreatmentsPharma Firms Competing to ‘Own The Disease’

Payer-Provider Integration Incentive AlignmentRisk Shifting

Consumer EngagementValue Based Benefits Wellness/Preventative Programs

Population Models (e.g., PCMHs, ACOs)Condition Oriented Models (COEs, DM programs)

Key Drivers

Business Model

Enablers

Convergence Care Model RedesignConsumerism

Technological

Enablers

‘Big Data’ Personalized MedicineMobility

Various economic, technological, regulatory and social factors are pushing the industry in new directions, creating problems that never before existed.

Drivers and Enablers of Change



The Past

Employers, payersRisk

Reimbursement

Service/volume-based

2000 2010 2015 2020

Delivery Hospital-based, expert/specialist driven

Community/retail-based, team driven

Information Siloed, static, paper-based

Treatment One-size-fits-all, volume-based

2005

Personalized, value-based

Networked, dynamic, digitally-based

Performance/value-based

Providers, patients

The Future

Physicians are in the unique position to help shape the industry’s future.

Healthcare transformation has afforded physicians unprecedented opportunities to shop their medical degrees to firms tasked with solving today’s issues.

Where is the industry going?


Healthcare Reform

ISSUESHigh cost to families

■ Average insurance $14,000/ family and has doubled in last 9 years

■ Aging population with more health problems

High Cost To Federal Government

■ Fastest growing segment of federal budget

Holes in coverage

People who need insurance most often turned down by preexisting conditions, lifetime limits, small business costs

1 in 7 had no insurance or under insured

Health care organizations should take offensive and defensive strategic responses to these drivers:


Healthcare Reform

ISSUES

SOLUTIONS

Insurance Reforms (no lifetime limits, limit preexisting conditions)

Adjustments to Government programs (Medicaid expansion, Medicare Drug program)

Health Insurance marketplace / exchanges (more competition)

Insurance Mandate - required insurance coverage (32 million new insured people)



Healthcare Reform

ISSUES

SOLUTIONS

IMPACT

$200 Billion savings over 10 years (2% of Budget and 3% of overall Healthcare spending)

DON’T IMPACT DEFICIT. Must be paid from savings from Healthcare Providers, Medicare Insurers with less reimbursement and new taxes on healthcare companies and individuals

$124 Billion in potential additional savings over 10 years

Source: http://obamacarefacts.com/costof-obamacare.php

In 2012 U.S. health care spending increased 3.7 percent to reach $2.8 trillion, or $8,915 per person



Healthcare ReformHealth care organizations need to take offensive and defensive strategic responses to these drivers.

Quality reporting• Pay for performance• Regulatory influence• Transparency/data sharing

New SustainableBusiness Model

Federally mandated programs that focus on quality and patient

safety

2013: Administrative simplification

2014: Exchanges

open to individuals and small

employers

2011: Minimum

medical loss ratio and rebates

2017: Exchanges

open for large employers

2012: Medicare

Advantage STAR Quality-

based payments

Fall 2011: CMS ACO

application period

2013: Episode-based payment pilots

begin

2012: CMS ACOs

begin

Value-based incentives and

avoidable readmission

penalties

2015: HITECH penalties

begin

HealthcarePlans

HealthcareProviders


The Healthcare Journey

Are we on diverging or converging paths?


Innovate


Heath System Transformation

Acute Care System 1.0

---

Episodic Non-IntegratedCare

Coordinated SeamlessHealthcare System 2.0

---

Outcome AccountableCare

Community IntegratedHealthcare System 3.0

---

Community IntegratedHealthcare

Episodic health care Lack integrated care networks Lack quality and cost

performance transparency Poorly coordinate chronic care

management

Patient/person centered Transparent cost and quality

performance Accountable provider networks

designed around the patient Shared financial risk HIT integrated Focus on care management

and preventive care

Healthy population centered Population health focused

strategies Integrated networks linked to

community resources capable of addressing psycho social/ economic needs

Population-based reimbursement

Learning organization capable of rapid deployment of best practices

Community health integrated E-health and telehealth

capable

Overview

Source: Neal Halfon, UCLA Center for Healthier Children, Families & Communities 15Copyright © 2014 FTI Consulting, Inc.

New Business Models

Patient Protection and Affordable Care Act of

2010 encourages providers to take

responsibility for the cost and quality of care and enables the formation of

ACOs.

Shared-Savings ProgramCenters for Medicare and Medicaid

Services (CMS) created shared-savings program for accountable

care organizations (ACOs)

ACOsGroups of hospitals and doctors

committed to reducing the cost and improving the quality of care

Accountable Care Organization

Clinically Integrated Network

Other


Level 1 - In Patient Acute CareLevel 2 - Post Acute Care

Level 3 - Chronic Condition Management

Level 4 - Population Health Management

Quality Over Quantity (Value

over Volume)Assuming increased financial and clinical

accountability

New Business Models

Accountable Care

Organization (ACO)

Value-Based Care(VBC)

Care Coordination

The ACO is the centerpiece of a

Clinically-Integrated Network Model



Volume (expanding exponentially) social media, household appliances, automobiles, stop lights blood pressure cuffs, smart scales, diabetes monitor, exercise

equipment

Velocity (rate at which volume is being generated) From the beginning of time to 2003, we produced 5 exabytes

(10006) of data. From 2003 to 2012 we produced 2.7 zettabytes (10007), or 500x

more data. From 2012 to 2015 we will produce three times more data than

between 2003 and 2012.

Variety (types of data being produced) documents, data (stock ticker), photos, audio, video, 3D models,

location data, unstructured data

Big Data, Big Impact

Traditional data management no longer works.


The volume and quantity of data needed to analyze population health in hospitals and health systems has not existed historically in healthcare.

Healthcare organizations have not invested in data and statistical analysis-based competencies• Data quantity, prediction, data

analysis population sets, statistics, insurance actuaries, etc.

Data Driven, John Morrissey, Hospitals & Health Networks, 2013*McKinsey Global institute

Is Big Data Worth The Effort?$300 billion potential impact in exploiting Big Data in healthcare*


= FTC & CLIO Payer Requirement (2014)

= At-Risk Population Management – Risk Stratification Requirement (Timing TBD)

Improving Healthcare Through Enhanced Technology

PatientEngagement/ Outreach

• Patient Portal• Patient Education• Mobile Applications• Automated Reminders• Response Tracking• Patient Assessments• Wellness Programs

Care Management/ Coordination

• Patient Registries• Care Gap Reporting/

Alerts• Visit Planner/Patient

Summary• Care Transitions &

Coordination • Clinical Decision

Support• EMR Integration

Clinical Data Capture& Analytics

• Data Repository• Claims Data Handling• Terminology Mapping• Physician Score-

carding• Existing Quality

Measures• External Benchmarking• EMR Interfaces• Clinical Data Handling

Population RiskStratification/ Management

• Predictive Risk Models• Care Gap Reporting• Customizable Filters• Performance

Reporting• Provider Dashboards


Accelerate


■ Operational Performance – generally dealing with status quo acute hospital care and how to cut costs and improve revenue

■ Clinical Quality – movement towards outpatient home care, clinical outcomes, patient preferences, and national campaigns, such as Choosing Wisely

Comprehensive Quality ImprovementTwo Fundamental Optimization Pathways


Comprehensive Quality Improvement:

Time, Complexity, & Difficulty

Valu

e, R

isk

& R

ewar

d

V

Operational Performance Optimization

Revenue – Revenue IntegrityLabor – Span of Control, HRSupplies – Standardization & UtilizationTech – EHR OptimizationClinical – LOS, Utilization, VariabilityPhysicians - Enterprise & CARTS

Revenue – AR & BillingLabor – BenchmarkingSupplies – GPOs & PricingTech – HIS + Bolt-onsClinical – Effectiveness

Revenue – Patient Access, DenialsLabor - Process InnovationSupplies – Purchased ServicesTech – EHR ImplementationClinical – Value-Based Purchasing(e.g., Readmissions)

Revenue – Call Center, Hospital & Physician IntegrationLabor – Shared ServicesSupplies – Strategic RelationshipsTech – Business IntelligenceClinical – Integration/ Risk Contracting/ Population Health, Reinventing Care DeliveryPhysicians – Network DevelopmentScale - Merger/ IntegrationCulture – Learning Organization, Patient Empowerment


Clinical Quality Improvement:

Three Core Metric Objectives

Functional Status

Morbidity

Rate

MortalityRate


Clinical Quality Improvement:

Impact Evaluation Metrics

QualityCare gap closurePeer reviewCare pathway compliance

Outcomes/Health Status

Potentially preventable admissions (PPAs)

ReadmissionsOther potentially

preventable events

Satisfaction/Quality of Life

Patient satisfactionProvider satisfactionMD/staff retention rates

Process/Behavior Change

Health Risk Assessments completed

ED wait timesSmoking CessationBMI Reduction

Efficiency/RiskAcute Length of Stay by

DRG/CPT, etc.Effective coding for

Population Health Management


Our Nation: Nutrition, Physical Activity, and Obesity


Rates of obesity are high in all states among adultsProgress in Nutrition, Physical Activity, and Obesity

Copyright © 2013 FTI Consulting, Inc. 28Copyright © 2014 FTI Consulting, Inc.

Progress in nutrition, physical activity, obesity, and food safetyProgress in Nutrition, Physical Activity, and Obesity

From 2008-2011, obesity among low-income preschoolers declined in 19 of 43 states and territories studied.

Copyright © 2013 FTI Consulting, Inc. 29Copyright © 2014 FTI Consulting, Inc.

Our Nation: Tobacco Use


Adult smoking rates vary widelyNearly 3x higher in some states than in othersTobacco Use


Many states have passed smoke-free laws in worksites, restaurants, and barsTobacco Use


Collaborate


The goal of population health management is to keep a patient population as healthy as possible, minimizing the need for expensive

interventions.

Proactive preventive and chronic care to all of a patients during and between encounters

Manage high-risk patients to prevent them from becoming unhealthier and developing complications

Use of evidence-based protocols to diagnose and treat in a consistent, cost-effective manner

Population Health

Accountable Care

Patient Registries

Care Teams

Disease Manageme

nt

Patient-Centered Medical Home

Coordinated Care

Population Health – The First Line of Defense


Population Health:

Transitioning to Value is a Huge Change


Current View30 Patients per Day14 have Chronic ConditionsUnknown Health RisksOffice Visits too short for coaching

New Population View2500 Patient Population900 have Chronic Conditions1100-1250 have Moderate/High Health RiskCare Teams leveraged by HIT

Volume-Based/Episodic Care Value-Based/Continuous Care


Population Health:

A Model

CommunityHealth

ChronicDisease

Payment Rewards

Behavioral

Health

Health vs.Care

PublicHealth

PublicSafety

K-12Education

Community

Investment

Ref.: Truman Medical Centers

Population Health

Dynamics:


Population Health

Interactive Stakeholders:


PolicyMakers/

Advocates

Patients/Community

Politicians

ClinicalProviders

Pharma/Medical Devices/Vendors

Patient/Communi

tyAdvocate

s

Public Health

Agencies

Educational

Systems

Purchasers

Payers

HealthSystems

Public Health and Healthcare Opportunities to Work Together on Population Health

Source: Georgia Department of Public Health

Linking the Medical Home, Public Health Services and the Hospitals

Quality Improvement

Community Engagement

Shared Health Assessment and Health

Improvement Planning

Care Extension and Case

Management

Designing Billable

Community-Clinical

Interventions

1 2 3

4 5 6


Logic will get you fromA to B

Imagination will take you everywhere

- Albert Einstein

Doing Care Differently: Journey to a Healthier Kentucky

A Final Thought


Prepared by:

Phillip L. Polakoff, MD, M.Env.Sc., MPH Senior Managing DirectorChief Medical ExecutiveHealth SolutionsFTI [email protected]


Documents

Doing Care Differently: The Journey to a Healthier Kentucky Innovate, Accelerate, Collaborate 2014 Howard L. Bost Memorial Health Policy Forum September