PopulationHealth
System Integrator
PatientExperience
The System Integrator
Creates a partnership across the medical
neighborhood
Drives PCMH primary care redesign
Offers a utility for population health and financial management
Per Capita Cost
Productivity
The Quadruple AimReadiness, Experience of Care, Population Health, Cost
28 Copyright 2011 by IBM
How Ohio BEAT the HEAT Zero Death !!!
How Ohio BEAT the HEAT Zero Death !!!
2010 2011ER visits -6.6% -9.9%Primary care sensitive ER Visits -7.0% -11.4%Ambulatory care sensitive Hospitalizations (per 1,000) -11.1% -22.0%
State Michigan working with BCBS Dow, IBM, Autos $ 7.5 PMPM investment $18 PMPM return
Copyright 2011 by IBM12
PCMH North Dakota Congratulations FIRST with all DOCs PCMH!! a hospitalization rate 18 to 24 percent below average hospital stays 38 percent shorter an amputation rate among diabetics 60 percent
lower than average Increased in value-based, targeted pharmaceutical
agents in support of chronic disease evidence-based standards.
most remarkable of all, these improved outcomes have come with a decrease total cost.
In ND Would Zsa zsa still have a leg to stand on your MOM??
Copyright 2011 by IBM14
36.3% Drop in hospital days32.2% Drop in ER use 12.8% Increase Chronic Medication use -9.6% Total cost 10.5% Inpatient specialty care costs down18.9% Ancillary costs down 15.0% Outpatient specialty downOutcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence from Prospective Evaluation Studies in the US K. Grumbach & P. Grundy, November 16th 2010
Smarter Healthcare
Copyright 2011 by IBM13
Copyright 2011 by IBM
Actual client data: Midwest Hospital with 12,135 employees 1 year self-funded for group health
$569
$805
17
$804
$765
Per Employee Per Month Health Costs
Post Implementation
Hospital build own Employee PCMH State JoinsHospital build own Employee PCMH State Joins
Why Innovate? Affordability
Costs continue their upward climb with employers paying much of the tab
Source: Dr. Martin Sepulveda Source: Dr. Martin Sepulveda Copyright 2011 by IBM
- Employer Cost - Employee Payroll Contributions - Employee Out of Pocket Expenses
5
The elephant in the room
2001 2009 2019
118%
166%
The Cause? Mostly due to fee-for-service payments and an over reliance on rescue/specialty care. This is stark evidence that the U.S. health care Industry has been failing us for years “Commonly cited causes for the
nation's poor performance are not to blame - it is the failure of the delivery system!!”
- Unaccountable Care Organizations!!! *Source: Peter A. Muennig and Sherry A. Glied Health Affairs Oct. 7, 2010
Dubuque, Iowa Genesse, MI
Ogden, UTFargo, ND
Dubuque, Iowa Genesse, MI
Ogden, UTFargo, ND
USA 2011USA 2011
Copyright 2011 by IBM20
Least Expensive Most Expensive Ogden, UT $2,623 Dubuque, IA $2,719 Genesee, Mi $2,957
Anderson, IN $7,231
Punta Gorda, FL $7,168
Racine, WI $6,528
Cost of Commercial lives
22 Copyright 2011 by IBM
WellPoint's New Hire - What Is Watson?
Copyright 2011 by IBM19
OHIO
PCMH Practice redesign - Promotion and widespread adoption of the patient-centered medical home practice model
Ohio Primary Care Workforce Collaborative (198) Benefit redesign to value based –Ohio as employer.
Payment reform – CPR value vs volume Engaged Business and Industry Leaders
PreventiveMedicine
Behavioral Health
MedicalAssistants
MedicationRefills Acute
Care
NursingCase
Manager
Test Results
HealthcareSupport
Team
ChronicDisease
Monitoring
DOCTOR
Practice Transformation Episode of Care Over
Source: Southcentral Foundation, Anchorage AK
Medical information is doubling every 5 years, much of which is unstructured
81% of physicians report spending 5 hours or less per month reading medical journals
Healthcare Industry is beset with some of the most complex information challenges we collectively face –In fact the current structure has failed us.
Source: International Journal of Circumpolar Health, DoctorDirectory.com, Institute for Medicine"
Payment reform requires more than one method, you have dials, adjust them!!!
“Pay for health”
“Pay for outcome”
“Pay for Management “Pay for Coordination
“fee for good service”
“Pay for satisfaction”
“Pay for health”
“Pay for outcome”
“Pay for Management “Pay for Coordination
“fee for good service”
“Pay for satisfaction”
32 Copyright 2011 by IBM
17
% Total Healthcare
Spend
% of Members
Benefit Redesign - Patient Engagement Different Strategies for Different Healthcare Spend Segments
Those who are well or think they are well
Those with chronic illness
Those with severe, acute illness or injuries
17
FEHB Program Carrier Letter All Carriers U.S. Office of Personnel Management-Federal Employee Insurance Operations -Letter No. 2012-09
We are reinforcing our support for patient centered medical homes (PCMH). We are again calling for to increase FEHBP members’ access to primary care providers who have adopted the principles of the medical home..
29 March 2012 29 March 2012
OPM and PCMH level care
OPM Technical guidance 19 April 2012 requires all Plans to Submit:
Criteria for PCMH recognition Percent and listing of all plans that have reached certification Number of covered lives in PCMH Recommended Provider payment incentives Plan to invite Patient into PCMH level care Quality outcomes associated with PCMH Inclusion in all CMS and state PCMH initiatives efforts (like
CPCi , MAPC).
OPM $39 Billion Book with Accountable CarePatient at the Center
24-7 clinician phone response Provide open scheduling. Provide care management and
coordination by specially-trained team members.
Use an EHR with decision support.
Use CPOE for all orders, test tracking, and follow-up.
Medication reconciliation for every visit.
Prescription drug decision support.
Implement e-prescribing. Registry
Pre-visit planning and after-visit follow-up for care management.
Offer patient self-management support.
Provide a visit summary to the patient following each visit.
Maintain a summary-of-care record for patient transitions.
Email consultations. Telephone consultations. The development of care
plans. Performance outcome measures.
Copyright 2011 by IBM31
Multi-state and National exchange
- Section 1334
OPM base of the multi-state exchange and the national exchange -- everyone is so focused on the states they miss the fact that OPM under the law is the agent for the other two exchanges it is built on this carrier letter.
OPM requirements are found in Section 1334 of the ACA for OPM to contract with health insurers to offer multi-state qualified health plans ("MSQHPs") to the individual and small-group markets.
The contours of OPM's implementation of the MSQHP contracts will have a significant impact on health insurance issuers that will participate in the state-based "American Health Benefit Exchanges" ("Exchanges") for the individual and small-group markets.
CPCI Five Functions/Framework For Comprehensive Primary Care
Risk stratified care management Access and continuity (24/7 with EMR) Planned care for chronic conditions and
preventive care (proactive management) Patient and caregiver engagement Coordination of care across the medical
neighborhood
22
COLORADO 18% decrease in acute IP admissions/1000, compared to 18% increase in control group
15% decrease in total ER visits/1000, compared to 4% increase in control group
Specialty visits/1000 remained around flat compared to 10% increase in control group
Overall Return on Investment estimates ranged between 2.5:1 and 4.5:1
PCMH Preliminary Year 2 Highlights
NEW HAMPSHIRENEW HAMPSHIRE
New York
Large company RFP -Patient Centered Medical Home
Are you doing anything to build community support for members by collaborating with Primary care physicians in initiatives such as patient centered medical homes. If so, please describe and note how this could impact or company.
If not building patient centered medical homes actively you will not be considered for 2012.
Forbes- "Primary Care Spring" unleashed by IBM. Forbes- "Primary Care Spring" unleashed by IBM.
BUYINGVALUE July 18 2012 Employers Buy Health Care That’s Proven to Work
PRIVATE PURCHASERS OF HEALTH COVERAGE JOIN FORCES
TO ALIGN with Medicare and OPM WITH SHIFT TO VALUE PURCHASING
BUYINGVALUE July 18 2012 Employers Buy Health Care That’s Proven to Work
PRIVATE PURCHASERS OF HEALTH COVERAGE JOIN FORCES
TO ALIGN with Medicare and OPM WITH SHIFT TO VALUE PURCHASING
The World Changed Jan 27th 2012 Insurer WellPoint to revamp primary care
pay January 27, 2012 The Associated Press An Rx? Pay More to Family Doctors WellPoint
to invest 1 Billion in primary care transformation.
“Patient Centered Medical Home” model emphasized in Anthem initiative
UNITED HC see you 10 raise you Conversation with OPM Yesterday - Ways
and Means and what that means
The Foundation: Patient Centered Primary Care
WellPoint strategy will drive transformation to a patient-centered care model by aligning economic incentives and giving primary care physicians the tools they need to thrive in a
value-based reimbursement environment.
Benefit design tied to measurable behavior changes and outcomes
Expanded access through innovation
Aligning care management with the delivery system
Exchange of meaningful information
Four Foundational Pillars
WellPoint - Patient Centered Primary Care (PC2) Strategy – A bold and aggressive plan
This strategy represents an aggressive and fundamental shift in how we interact with and engage primary care physicians on all levels:
clinically, contractually, operationally and culturally.
This strategy represents an aggressive and fundamental shift in how we interact with and engage primary care physicians on all levels:
clinically, contractually, operationally and culturally.
OUR Patient needs A long-term comprehensive relationship with a Personal Physician empowered
with the right tools and linked to their care team.
Copyright 2011 by IBM8
The Joint Principles: Patient Centered Medical Home Personal physician - each patient has an ongoing relationship with a personal
physician trained to provide first contact, and continuous and comprehensive care
Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients
Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or arranging care with other qualified professionals
Care is coordinated and integrated across all elements of the complex healthcare community- coordination is enabled by registries, information technology, and health information exchanges
Quality and safety are hallmarks of the medical home-
Evidence-based medicine and clinical decision-support tools guide decision-making; Physicians in the practice accept accountability voluntary engagement in performance measurement and improvement
Enhanced access to care is available - systems such as open scheduling, expanded hours, and new communication paths between patients, their personal physician, and practice staff are used
Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home- providers and employers work together to achieve payment reform
Copyright 2011 by IBM9
Superb Access to Care
Patient Engagement in Care
Clinical Information Systems
Care Coordination
Team Care
Patient Feedback
Publicly Available Information
Defining the Care Centered on Patient
30 Copyright 2011 by IBM
Trajectory to Value Based Purchasing: Achieving Real Care Coordination and Outcome Measurement
34 Copyright 2011 by IBMRegistry Registry
+ +
An opportunity to think and act in new ways—Not master-builder but Master plan DATA DRIVEN
OUTCOMES based!!
From Episode of Care to Population Management at the Personal level -- Centered on the Patient
IntelligentInstrumented Interconnected
=
NJ Patient-Centered Medical Homes Drive Quality and Cost Improvements
152 physicians at 22 practices within ten counties.
Quality Measures 8% higher rate in improved diabetes
control (HbA1c) 6% higher rate in breast cancer screening 6% higher rate in cervical cancer screeningCost and Utilization Indicators 10% lower cost of care (per member per
month) 26% lower rate in er visits 25% lower rate in readmissions 21% lower rate in inpatient admissions
10 April 2012 10 April 2012
2011 Towers Watson Healthcare Cost SurveyBureau Labor Statistics, US DOL 2011 Towers Watson Healthcare Cost SurveyBureau Labor Statistics, US DOL
Copyright 2011 by IBM
Savings per employee
$2,830 per employee
$4,025 per employee
$5,486 per employee
$7,264 per employee
$9,420 per employee
18
PCMH level Clinic Competitive Advantage
Expected with Clinic
Expected
Years of PCMH implementation
Annual per employee group health savingsAdvantage grows dramatically over time
10Trained & Engaged
Leadership
10Trained & Engaged
Leadership
8Coordination of care
8Coordination of care
9
Template of the future
9
Template of the future
5Population
Management
5Population
Management
Building Blocks of High-Performing Primary Care April 2012 Center For Excellence in Primary Care
Building Blocks of High-Performing Primary Care April 2012 Center For Excellence in Primary Care
6 Continuity
of care
6 Continuity
of care
7Prompt
access to care
7Prompt
access to care
1 Shared Vision & Goals
1 Shared Vision & Goals
2 Data-driven
Improvement
2 Data-driven
Improvement
3Empanelment & panel size
management
3Empanelment & panel size
management
4Team-based care
4Team-based care
11% CMS Shift in payment away from FFS to other dials.
CMS Bundling!! CMS Advanced Primary Care
Wellpoint PCMH, BCBS Hawaii no new FFS $$
CMS Plus most other buyers CMS Plus most other buyers
Copyright 2011 by IBM33
Don’t handle your care needs in a BAD MEDICAL NEIGHBORHOOD!!
Unaccountable care, lack of organization, DO NOT GO THERE ALONE !!
Be wise when you pay for care, KNOW WHAT YOU BUY!!
Copyright 2011 by IBM21
“We don't have a health care delivery system in this country. We have an expensive plethora of uncoordinated, unlinked, micro systems, each performing in ways that too often create sub-optimal performance, both for the overall health care infrastructure and for individual patients." George Halvorson, from “Healthcare Reform Now”
Coordination -- we do NOT know how to play as a team
26 Copyright 2011 by IBM
40
Benefit PlanPaid Claims – Calendar Year 2010
% Total Healthcare
Spend
% of Members
Ten percent of the population consumes 66% of the total spend (members with > $10,000 in expenses)
49% of the population consumes only 4% of the total spend (each spends < $1,000)
So simple!So much!
If you scan the world for value based healthcare, you will find a common element: a relationship-based team with a project manager! A comprehensivist that can command and control in an accountable system.
29 Copyright 2011 by IBM
Public Health Prevention
Specialists
PCMH in Action Vermont “Blueprint” model
Community Care Team
Nurse CoordinatorSocial Workers
DieticiansCommunity Health Workers
Care Coordinators
Public Health Prevention HEALTH WELLNESS
Hospitals
PCMH
PCMH
Health IT Framework
Global Information Framework
Evaluation Framework
Operations
A Coordinated Health System
35 Copyright 2011 by IBM
Vermont Financial Impact
Patientis the center
of theMedical Home
Population Health
Patient-Centered
Care
Refocused Medical TrainingPatient &
Physician Feedback
Advanced IT Systems
Access to Care
Team-Based Healthcare
Delivery
Decision Support Tools
Model adapted from theNNMC Medical Home
Enhancing Health and the Patient Experience
Medical Home Model
Care that is Accountable
39 Copyright 2011 by IBM
PATIENT CENTERED MEDICAL HOME: PATIENT CENTERED MEDICAL HOME: VHA Patient Aligned Care TeamVHA Patient Aligned Care Team
Replaces episodic care based on illness and patient complaints with coordinated care and a
long term healing relationship
40 Copyright 2011 by IBM
Individual Behaviors with Payment and Benefit Reforms
46
Fee for Service Bundled Payments Shared Savings GlobalCapitation
Benefit Plan SteerageTiered networks Tiered networks
Member obligationsTiered networks Gatekeeper
Patient choice of providers
Autonomy Autonomy “Attribution” “Assignment”
Administrative complexity
Well understood by payers and providers
Complex Extremely complex Well understood by some providers and payers
Risk to Providers Minimal Moderate Substantial Substantial
Ability of providers to manage utilization and outcomes
No incentive Substantial within the bundle
Uncertain Substantial across
Support for care management
Minimal at best Built into budget for bundle
Timing issue Supported
Risk to payers
Substantial, even with external UM
Controlled Substantially controlled
Can be totally controlled within the cap budget
According to the study by NEHI, U.S. health care costs are wildly out of alignment with the actual determinants of health. About 50 percent of health status is determined by diet, exercise, smoking, stress and safety—or lifestyle choices and available options; 20 percent by exposure to environmental toxins; 20 percent by genetic predisposition; and just 10 percent by access to health care. Yet the vast majority—88 percent—of Americans’ health dollars are spent on access to care and treatment, with just four percent spent on lifestyle options and choices and eight percent on environmental and genetic factors. This mismatch results in higher and higher costs for less and less health benefit. While many Americans believe that our health care system is the best in the world, the fact is that our health relative to other nations, which spend much less per capita, is slipping, even for survival rates among adults age 45–55.
According to the study by NEHI, U.S. health care costs are wildly out of alignment with the actual determinants of health. About 50 percent of health status is determined by diet, exercise, smoking, stress and safety—or lifestyle choices and available options; 20 percent by exposure to environmental toxins; 20 percent by genetic predisposition; and just 10 percent by access to health care. Yet the vast majority—88 percent—of Americans’ health dollars are spent on access to care and treatment, with just four percent spent on lifestyle options and choices and eight percent on environmental and genetic factors. This mismatch results in higher and higher costs for less and less health benefit. While many Americans believe that our health care system is the best in the world, the fact is that our health relative to other nations, which spend much less per capita, is slipping, even for survival rates among adults age 45–55.
Reinventing Medicaid findings are Outstanding
Oklahoma's patient-centered medical home initiative has reduced Medicaid costs $29 per patient per year from 2008 to 2010. Moreover, use of evidence-based primary care, including screening for breast and cervical cancer, increased.
The Colorado initiative expanded access to care. Before the initiative, only 20 percent of pediatricians in the state accepted Medicaid; as of 2010, 96 percent and did and at a lower cost to the state.
Vermont, inpatient care use and related per-person per-month costs decreased 21 percent and 22 percent, respectively, from July 2008 to October 2010. ER use and related per-person per-month costs decreased 31 percent and 36 percent, respectively.
Patient Centered Medical Home in Washington in State Acute care spending there was 18 percent below the national average. Inpatient stays per beneficiary were 35 percent below the national average.
Source -- M. Takach, "Reinventing Medicaid: State Innovations to Qualify and Pay for Patient-Centered Medical Homes Show Promising Results," Health Affairs, July 2011 30(7):1325–34. Source -- M. Takach, "Reinventing Medicaid: State Innovations to Qualify and Pay for Patient-Centered Medical Homes Show Promising Results," Health Affairs, July 2011 30(7):1325–34.
The Bottom Line in Medicaid PCMH starting to show an impact in access to care, quality, and cost control .
The Bottom Line in Medicaid PCMH starting to show an impact in access to care, quality, and cost control .
41 Copyright 2011 by IBM
42 Copyright 2011 by IBM
PCMH is non-political – the right POV for delivery transformation
“We never abandoned advocating newModels of care. We’ve long pushed folksto realize that Delivery reform is the key.”The patient-centered medical home iscore.
“We included the attached chapter on PCMH in our book. and have a new publication on ACOs coming out in January.”
44 Copyright 2011 by IBM
Source Int’l Federation of Health Plans:2010 Healthcare Price Report Source Int’l Federation of Health Plans:2010 Healthcare Price Report
Copyright 2011 by IBM25
CAN FRA GER NETH SPA SWIZ UKUS
(avg)
US(95th
%ile)
Appen-dectomy
$3,810 $2,795 $3,285 $4,624 $2,537 $2,570 $3,476 $13,123 $25,344
HipReplace-ment
$10,753 $12,629 $15,329 $12,737 $9,327 $6,683 $9,637 $34,454 $75,369
BypassSurgery
$22,212 $16,325 $27,237 $19,180 $15,802 $11,618 $13,998 $59,770 $126,182
Total Hospital and Physician Costs for Select Surgeries – International Comparisons
Patients love to see meaningful information about themselves and it takes IT tools to If you give patients educational materials with their
name on it and with their data analyzed in it, they will read it, pour over it and discuss it with you.
If you tear off a generic sheet and give it to them, it often goes in the waste basket.
If you give patients an analysis of their health risk AND if you include a “what if” scenario, i.e., what will their health risk be if they make a change; you can prove it to them
“If you the healer make a change, it will make a difference to your patient.”
43 Copyright 2011 by IBM
If we truly want to understand costs and where they can be reduced without compromising outcomes, we need to aggregate costs around the patient. (need a place to do that – that is PCMH)
The way care is currently organized leads to redundant administrative costs, unnecessary and expensive delays in diagnosis and treatment, and unproductive time for physicians.
A system integrator a place where data is aggregated, understood and held accountable at the level of the individual patient -- THAT IS PCMH. In fact, cost reduction will often be associated with better outcomes.
The Big Idea: How to Solve the Cost Crisis in Health Care,Robert S. Kaplan and Michael E. Porter Sept 2011 Harvard Review
Copyright 2011 by IBM6
ACO and the Principles of the PCMH
Whether building a community-wide ACO or a solo primary care practice, adherence to guiding PRINCIPLES provides the foundation. Through the PCMH Joint Principles, we (the buyers and providers) have agreed to change our covenant with one another. The Joint Principles of the PCMH have been agreed on by those who deliver comprehensive care (the primary care providers) and their specialist colleagues. For Accountable Care to achieve its goals, successful organizations will NEED a foundation in these principles.
As a buyer, I want to be assured that the foundation - the principles - are in place: a personal relationship with a healer, improved access, care that is coordinated, integrated and comprehensive.
Copyright 2011 by IBM10
PCMH is the patients view from the bottom up. The kind of care they want: relationship, accessible, coordinated
From the System view it is ACO
Or, like the Euro tunnel you can start on one side building PCMH and the other side ACO, but somewhere you have to meet in the middle, where care is delivered- centered on the needs of the patient.
Copyright 2011 by IBM11
Copyright 2011 by IBM
Cost per Case Comparison
16
Savings Gap
Savings Gap Savings
Gap
Savings Gap
$1231 savings per case after contract
implementation
$2085 savings per case after contract
implementation
$3105 savings per case after contract
implementation
$1548 savings per case after contract
implementation
Who was Who was the the Shooter’s Doctor?Shooter’s Doctor?
Away from Away from Episodes of Care - Episodes of Care - FFS FFS
Population management !!
Accountability !!
Population management !!
Accountability !!
Copyright 2011 by IBM3
Parachute use to prevent death and major trauma related to gravitational challenge; systematic review of randomised controlled trials.
Parachute use to prevent death and major trauma related to gravitational challenge; systematic review of randomised controlled trials.
Smith GC, Pell JP. BMJ 327:1459-1461; 2003.Smith GC, Pell JP. BMJ 327:1459-1461; 2003.
Here is None _ Why ??
Here is None _ Why ??
Paul Grundy, MD, MPH, FACOEM, FACPM IBM Director Healthcare TransformationPresident Patient Centered Primary Care Collaborative
Paul Grundy, MD, MPH, FACOEM, FACPM IBM Director Healthcare TransformationPresident Patient Centered Primary Care Collaborative
NCQA NCQA
Computerworld Solution Honors Laureate
Computerworld Solution Honors Laureate
Dept of State Superior Honor Award
Dept of State Superior Honor Award