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POPULATIONHEALTH
thought leaders in
identifyingimplementation tactics
The Impact of Value-Based Purchasingand Other Employee Initiatives onPopulation Health
November 20, 2014
This presentation has been provided for informational purposes only and
is not intended and should not be construed to constitute legal advice.
Please consult your attorneys in connection with any fact-specific
situation under federal, state, and/or local laws that may impose
additional obligations on you and your company.
Cisco WebEx can be used to record webinars/briefings. By participating
in this webinar/briefing, you agree that your communications may be
monitored or recorded at any time during the webinar/briefing.
Attorney Advertising
POPULATION HEALTHthought leaders in
Identifying implementation tactics
Can Population Health Management Interventions Help State Medicaid Offerings?
December 18, 2014 at 12:00 p.m. ET
This session will focus on how state Medicaid programs are utilizing casemanagement and other population health management interventions toimprove clinical and financial outcomes. One major issue concerns ongoingbudgeting issues, along with how to bend the cost curve and generally “fix” theMedicaid system. The session also will touch base on how to best implementmeaningful population health programs where federal, state and local agenciesoften need to fund, pay for and coordinate care together.
Keep an eye out for the webinar invitation!
Upcoming Webinar!
3
POPULATION HEALTHthought leaders in
Identifying implementation tactics
David Lansky, PhD
President & CEO
Pacific Business Group on Health
Laurel Pickering, MPH
President & CEO
Northeast Business Group on Health
Adam Solander - Moderator
Associate
Epstein Becker Green
Webinar Presenters
4
POPULATION HEALTHthought leaders in
Identifying implementation tactics
This session will explore the activities of some well-known employer coalitionsand discuss how they are designing and implementing value-based purchasinginitiatives. Speakers will include an update on consumer-directed health,accountable care organizations (ACOs) and care management and wellnessprograms.
The webinar will focus on:
– Standardizing and reporting on performance measures
– Identifying the next wave in value-based purchasing
– Assessing the impact of the ACA and other health reform initiatives onemployers
– Engaging consumers in informed decision making
– Approaches to reduce costs and improve health care
Presentation Overview
5
POPULATION HEALTHthought leaders in
Identifying implementation tactics
The Pacific Business Group on Health (PBGH), a not for profit 501(c)(3), has ledefforts to transform health care using the combined influence of some of thelargest purchasers of health care services in the United States.
Pacific Business Group on Health
©PBGH 2014
6
POPULATION HEALTHthought leaders in
Identifying implementation tactics
PBGH Members
©PBGH 2014
7
AppleFacebookGoogleHewlett PackardMicrosoftOracle….
POPULATION HEALTHthought leaders in
Identifying implementation tactics
57%
119%
182%
56%
117%
196%
14%
34%
50%
11%
29%40%
0%
50%
100%
150%
200%
250%
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Health Insurance Premiums
Workers' Contribution to Premiums
Workers' Earnings
Overall Inflation
SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2013. Bureau of Labor Statistics, Consumer Price Index,U.S. City Average of Annual Inflation (April to April), 1999-2013; Bureau of Labor Statistics, Seasonally Adjusted Data from theCurrent Employment Statistics Survey, 1999-2013 (April to April).
$16,351*
$15,745*
$15,073*
$13,770*
$13,375*
$12,680*
$12,106*
$11,480*
$10,880*
$9,950*
$9,068*
$8,003*
$7,061*
$6,438*
$5,791
$5,884*
$5,615*
$5,429*
$5,049*
$4,824
$4,704*
$4,479*
$4,242*
$4,024*
$3,695*
$3,383*
$3,083*
$2,689*
$2,471*
$2,196
$0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000 $14,000 $16,000 $18,000
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999 Single Coverage
Family Coverage
Cumulative Increases in Health Insurance Premiums, Workers’Contributions, Inflation, and Workers’ Earnings, 1999-2013
©PBGH 2014
POPULATION HEALTHthought leaders in
Identifying implementation tactics
Employers Considering “Exit”
Source: 19th Annual Towers Watson/National Business Group on Health Employer Survey on Purchasing Value in HealthCare (2014)
©PBGH 2014
9
POPULATION HEALTHthought leaders in
Identifying implementation tactics
1990s: Health plans and managed care
2000s: Skin in the game, account-based plans
2010s: Direct engagement with providers
High performing employers today:
– Strategies to alter provider payment
– Strategies to alter consumer decisions (“steerage”)
The Evolving Purchaser Strategy
©PBGH 2014
10
POPULATION HEALTHthought leaders in
Identifying implementation tactics
Three case studies (all from orthopedics):
1. Reference pricing
2. Centers of Excellence: Travel Surgery
3. Joint Replacement Registry: Patient Reported Outcomes
One case study of purchaser-driven ACO (from the city of San Francisco)
Purchasers’ Approach to “Episodes” and ACOs
©PBGH 2014
11
POPULATION HEALTHthought leaders in
Identifying implementation tactics
Price varies from $15,000 to $110,000 (commercial PPO population)
Anthem Blue Cross and CalPERS established a threshold of $30,000–referenceprice–for standard inpatient hip/knee replacement procedure
Increased volume of products at low-cost hospitals by 21%
Amount paid per surgery 20% lower across all cases
CalPERS: Applying Reference Pricing toHip/Knee Replacements
©PBGH 2014
Source: Robinson JC and Brown TT, “Increases in Consumer Cost Sharing Redirect Patient Volumesand Reduce Hospital Prices for Orthopedic Surgery.” Health Affairs 32(8), 2013, pp. 1392-1397.
12
POPULATION HEALTHthought leaders in
Identifying implementation tactics
Reference Pricing: Orthopedics
©PBGH 2014
Source: Robinson JC and Brown TT, “Increases in Consumer Cost Sharing Redirect Patient Volumes andReduce Hospital Prices for Orthopedic Surgery.” Health Affairs 32(8), 2013, pp. 1392-1397.
13
POPULATION HEALTHthought leaders in
Identifying implementation tactics
What is ECEN?
– Founding Purchasers (launched early 2014)
Employers Centers of Excellence Network(ECEN)
©PBGH 2014
14
POPULATION HEALTHthought leaders in
Identifying implementation tactics
Episode-based fees:
– Developed in partnership with providers
– Promotes coordination across services
– Encourages fair and competitive prices
– Single rate for “wheels up to wheels down”
ECEN: Bundled Payments
©PBGH 2014
15
POPULATION HEALTHthought leaders in
Identifying implementation tactics
Higher quality care
Supportive, seamless and integrated experience
Exceptional, patient-centered care
Lower out-of-pocket costs
Program Value for Employees
©PBGH 2014
16
POPULATION HEALTHthought leaders in
Identifying implementation tactics
High employee satisfaction
Cost predictability
Downstream savings
Return on investment within 2 years
Program Value for Employers
©PBGH 2014
17
POPULATION HEALTHthought leaders in
Identifying implementation tactics
Overview of COE Evaluation Criteria
©PBGH 2014
Employer Needs
Location
Bundled paymentdesign
Travel surgeryexperience
Reporting on COEperformance
Patient Experience
Shared decisionmaking
Supportiveresources
Attention to patientexperience acrossthe complete carecontinuum
Quality of Care
Outcomes data andrankings
Volume, trainingand experience
Patient safety andsatisfaction scores
Application ofevidence-basedmedicine
18
POPULATION HEALTHthought leaders in
Identifying implementation tactics
Virginia Mason Medical Center
Seattle, WA
Kaiser Permanente Irvine
Medical Center
Irvine, CA
Mercy Hospital, Springfield
Springfield, MO
Johns Hopkins Bayview
Medical Center
Baltimore, MD
COE Locations
©PBGH 2014
19
POPULATION HEALTHthought leaders in
Identifying implementation tactics
1,636 inquiries
348 surgeries performed
….? inappropriate referrals
Initial ResponseECEN 1/1/2014-9/30/2014
©PBGH 2014
20
POPULATION HEALTHthought leaders in
Identifying implementation tactics21
POPULATION HEALTHthought leaders in
Identifying implementation tactics
California Joint Replacement Registry: Notjust a device registry
©PBGH 2014
DEMOGRAPHICS
DEVICEINFORMATION
PROCEDUREINFORMATION
COMORBIDITIES
PROPHYLAXIS
READMISSIONS
PATIENT REPORTEDOUTCOMES
22
POPULATION HEALTHthought leaders in
Identifying implementation tactics23
POPULATION HEALTHthought leaders in
Identifying implementation tactics
Patient Reported Outcomes
©PBGH 2014
24
POPULATION HEALTHthought leaders in
Identifying implementation tactics25
POPULATION HEALTHthought leaders in
Identifying implementation tactics
1. Bundled payment for standardized episode
2. “Accountability” for outcomes (TBD)
3. Coordination with local referring and follow-up providers
4. Transparency on quality and cost; comprehensive quality dashboard
5. Commitment to continuous improvement collaboration
6. Participation in recognized, standardized registry with public reporting
7. Commitment to patient engagement, including shared decision making,patient reported outcomes and patient experience feedback
Key Elements of Ortho Network for LargePurchasers: Favorable Benefit Design
©PBGH 2014
26
POPULATION HEALTHthought leaders in
Identifying implementation tactics
Split between consumerist andintegrated care visions
Diversity of purchaser needs,beliefs and resources
Unusual adaptations byproviders and plans (e.g., Kaiserparticipation in Centers ofExcellence orthopedic network)
Are We All on the Road to ACOs? No!
©PBGH 2014
Survey source: 19th Annual Towers Watson/National Business Group on HealthEmployer Survey on Purchasing Value in Health Care, 2014.
27
POPULATION HEALTHthought leaders in
Identifying implementation tactics
Purchaser Strategies: Build or Buy?
©PBGH 2014
Build Your Own Buy from a Health Plan
Pros Pros
• Control provider network selection • Less start-up time
• Control design elements, includingcare management, quality metricsand payment model
• Leverage established managementinfrastructure and reporting
• Design for target market • Benchmark within a broadernetwork
Cons Cons
• Resource intensity (for theemployer)
• Limited ability to customize designand payment model
• Stability and sustainability • Limited network customization
28
POPULATION HEALTHthought leaders in
Identifying implementation tactics
Few ACOs can deliver on cost and quality today
Purchasers’ role is to raise the bar and simplify the performance requirements
Keep the focus on these principles:
– ACOs must be transparent
– ACOs must be outcomes-focused
– ACOs must be patient-centered
– ACOs must pay providers for quality, not quantity
– ACOs must address affordability and contain costs
– ACOs must support a competitive marketplace
– ACOs must demonstrate meaningful use of health information technology
Desired results will require intense collaboration, leadership and perseverance
Commit to multi-year transition to global payment and provider full risk for apopulation
Current State of Large Purchaser Thinking
©PBGH 2014
29
POPULATION HEALTHthought leaders in
Identifying implementation tactics
Collaboration between PBGH and Catalyst for Payment Reform
Model ACO Contract Language
– Purchaser expectations: aligned with principles
Performance metrics
User guide
– Sample financing/risk-sharing models
– Purchaser checklist and illustrative implementation timeline
Health plan questionnaire
Provider request for information
Case studies
ACO Toolkit Elements
©PBGH 2014
Available at: www.catalyzepaymentreform.org/?option=com_content&view=article&id=122
30
POPULATION HEALTHthought leaders in
Identifying implementation tactics
The Health Service System isdedicated to preserving andimproving sustainable, qualityhealth benefits and toenhancing the well-being ofemployees, retirees and theirfamilies
Programs cover 109,000 livesfor 4 employers (actives andretirees)
3 health plans: 2 HMOs and 1PPO
Also offer dental, vision, life,LTD and EAP
Health Service SystemCity and County of San Francisco
©PBGH 2014August 6, 2014
31
POPULATION HEALTHthought leaders in
Identifying implementation tactics
©PBGH 2014
32
POPULATION HEALTHthought leaders in
Identifying implementation tactics
CCSF ACOs: Sustaining Results
©PBGH 2014
ID Key Indicator Baseline 2013 Results % Change Direction
1. Admits/1000 52.2 53.0 1.4%
2.30 Day ReadmissionRate
8.5% 7.5% (-13.4%)
3. Days/1000 238.0 223.2 (-6.7%)
4. ALOS 4.56 4.21 (-8.2%)
5. ER Visits/1000 171.6 160.0 (-7.2%)
Membership1: 23,512 Average Risk Score2: 1.592 (Bay Area HMO: 1.47)
1. Membership as of December 20132. Risk Score is concurrent expenditure risk calculated using DxCG Version 3.03 as of December 20133. “Baseline" reflects July 1, 2010 through June 30, 20114. “2013 Results” reflects January 1, 2013 through December 1, 2013
33
POPULATION HEALTHthought leaders in
Identifying implementation tactics
Program Framework and Timeline
©PBGH 2014
Evaluate population/healthprofile
Establish financial &utilization targets
Establish governancestructure
Identify interventions
Design and buildexecution plans
Address short-term datashare requirements
Define process andoutcome measures
Evaluate and addressprogram barriers
Coordinated execution
Monitor process andoutcome measures
Refine, improve and expand
Increase physicianeducation & memberengagement opportunities
Design complex, moretransformationalinterventions
Add new
interventions
Evaluate long-term
transformational care
strategies
Address long-term
data share
opportunities
Refine, improve and
expand
Program evaluation
partnership launch &evaluation
low/medium complexity intervention execution;‘getting the basics right’
higher complexity; transformationalchange
multi-year partnership: maturity timeline
34
POPULATION HEALTHthought leaders in
Identifying implementation tactics
Shared interest in disruption, and accelerated adoption of new payment anddelivery models
Focused on “raising the bar” on performance
Interested in direct relationship with aligned provider systems
Recognized need for multiple, aligned interventions: payment, benefit design,transparency on outcomes and clinical improvement
Invested substantial resources in testing, spreading and scaling innovation
Conclusions About Large Employers
©PBGH 2014
35
POPULATION HEALTHthought leaders in
Identifying implementation tactics
Northeast Business Group on Health is a network of employers, providers,insurers and other organizations working together to improve the quality andreduce the cost of health care in New York, New Jersey, Connecticut andMassachusetts
Our mission is to empower our members to drive excellence in health andachieve the highest value in health care delivery and the consumer experience
Northeast Business Group on Health
36
POPULATION HEALTHthought leaders in
Identifying implementation tactics
NEBGH Employer Members
37
37
POPULATION HEALTHthought leaders in
Identifying implementation tactics
How does NEBGH empower our members?
How does NEBGH use that power to drive excellence in health and achieve thehighest value in health care delivery and the consumer experience?
NEBGH: Member Empowerment
38
POPULATION HEALTHthought leaders in
Identifying implementation tactics
Health Plans
– eValue8
– User Groups
• Aetna, United, Anthem and PBM
Education
– Topics: Employers working directly with providers, private exchanges,specialty pharmacies, health care innovators/disruptors, the ROI ofwellness programs, retail clinics, etc.
Empowering Employers
39
POPULATION HEALTHthought leaders in
Identifying implementation tactics
Evidenced-based health plan evaluation process
How does the plan use the information and contracts it has to improve thehealth of the member and the delivery system?
Sponsored by National Business Coalition on Health
NEBGH has participation from Aetna, Cigna, United and Anthem
eValue8
40
POPULATION HEALTHthought leaders in
Identifying implementation tactics
Health plans complete request for information (RFI)
Results are scored
Detailed feedback is provided to plans and employers
Comparative health plan reports are developed for plans and employers
Meeting is scheduled with employers and plan leadership to review results
eValue8 Process
41
POPULATION HEALTHthought leaders in
Identifying implementation tactics
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Cigna NJ UHC NJ Aetna NY Anthem NY Cigna NY UHC NY PPOBenchmark
PossiblePoints
17% 17%
5% 7%17% 17% 17%
21%
18% 15%
17% 13%
18% 15% 18%
20%
30%30%
34%
26%
30%30%
30%
38%
10%10%
11%
7%
10%10%
10%
11%
2%3%
3%
0%
1% 6%7%
9%
77% 75%
70%
53%
76% 78%82%
100%
Pe
rce
nt
of
Po
ssib
leP
oin
ts
Plan Design Capabilities Provider Information Treatment Option Support & PHR Price Transparency Performance Measures
2013 eValue8 ResultsConsumer Engagement
42
POPULATION HEALTHthought leaders in
Identifying implementation tactics
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Cigna NJ UHC NJ Aetna NY Anthem NY Cigna NY UHC NY PPOBenchmark
PossiblePoints
25% 29% 29%21% 25% 29% 25%
32%
11%10%
4%10%
11%10%
11%
12%
15% 9%
5% 8%
10% 7% 17%
20%
22%
9%
14%6%
13% 12%
30%
32%3%
2%3%
2%
2% 3%
2%
5%
76.8%
59.0%55.1%
46.7%
61.3% 60.7%
84.5%
100.0%
Pe
rce
nta
geo
fP
oss
ible
Po
ints
Coordination/Member Support Practitioner Support CAD Performance Diabetes Performance Other Conditions
2013 eValue8 ResultsChronic Disease Management
43
POPULATION HEALTHthought leaders in
Identifying implementation tactics
NEBGH serves as a neutral convener and catalyst for plans and other health carestakeholders
Multi-payer collaboration is key
Driving Value in Health Care Delivery
44
POPULATION HEALTHthought leaders in
Identifying implementation tactics
80% of anti-depressant prescriptions written by PCPs
PCPs need support (lack of knowledge, lack of referral base, etc.)
Proven model: “Collaborative Care Model”
Link a care manager and consulting psychiatrist
Need a multi-payer reimbursement strategy
Integrating Behavioral Health into PrimaryCare
45
POPULATION HEALTHthought leaders in
Identifying implementation tactics
Multi-payer strategy to integrate behavioral health into primary care
Aetna, Cigna, United Healthcare, Anthem and Emblem
Four primary care practices
Focus on paying for activities plans that patients don’t normally pay for
NEBGH One Voice Project
46
POPULATION HEALTHthought leaders in
Identifying implementation tactics
Multi-payer: Aetna, Cigna, United, Anthem and Emblem
One hospital system: NYU Langone Medical Center
How can we further reduce NYU’s readmissions?
Focus on increasing use of risk scores and coordinating care
Hospital Readmission Reduction Project
47
POPULATION HEALTHthought leaders in
Identifying implementation tactics
NEBGH Solutions Center
48
POPULATION HEALTHthought leaders in
Identifying implementation tactics
Questions
49
POPULATION HEALTHthought leaders in
Identifying implementation tactics
Can Population Health Management Interventions Help State Medicaid Offerings?
December 18, 2014 at 12:00 p.m. ET
This session will focus on how state Medicaid programs are utilizing casemanagement and other population health management interventions toimprove clinical and financial outcomes. One major issue concerns ongoingbudgeting issues, along with how to bend the cost curve and generally “fix” theMedicaid system. The session also will touch base on how to best implementmeaningful population health programs where federal, state and local agenciesoften need to fund, pay for and coordinate care together.
Keep an eye out for the webinar invitation!
Upcoming Webinar!
50
POPULATIONHEALTH
thought leaders in
identifyingimplementation tactics
Adam SolanderEpstein Becker [email protected](202) 861-0900
David Lansky, PhDPresident & CEOPacific Business Group on Health
1227 25th Street, NWWashington, DC 20037www.ebglaw.com
Laurel Pickering, MPHPresident & CEONortheast Business Group on Health
POPULATIONHEALTH
thought leaders in
identifyingimplementation tactics
THANK YOU
www.ebglaw.comwww.ebgadvisors.com