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Sustaining Population Health Outcomes
William J. Kassler, MD, MPH
Practical Playbook MeetingMay 2016
U.S Health in International Perspective
• US spends far more per person on health care
• Shorter life span, Poorer health
• Consistent and pervasive over entire life:
Infant mortality & low birth weight
Injuries & homicides
HIV/AIDS
Drug-related deaths
Obesity & diabetes
Heart disease
Chronic lung disease
Disability
Impact Of Obesity On Medical Spending: 1987 – 2001
• Obesity increased by 10% in population
• Spending for obese was 37% higher
than for non-obese
• Rate of growth in spending higher for
obese:
63% ↑ obese vs. 37% ↑ non-obese
• Obesity accounted for 27% of growth in
spending
Thorpe et al Health Affairs, no. (2004):10.1377
Socio-economics factors linked to poor health outcomes
• Area Deprivation Index (ADI)– Neighborhood-based composite measure
consisting of 17 markers of socioeconomic status
• ADI correlated with:– Mortality rates (age and race adjusted) for men
and women
– 30 day readmission rates • increase with worsening ADI
• Magnitude equal to COPD and > diabetes
Sources:Singh, GK Area deprivation and widening inequalities in US mortality, 1969-1998. Am J Public Health July 2003Kind, AJ et al Neighborhood socioeconomic disadvantage and 30-day rehospitalization: a retrospective cohort study Ann Intern Med Dec 2014
Determinants
SOCIAL, ENVIRONMENTAL, and BEHAVIORAL
FACTORS(60%)
GENETICS(20%)
HEALTH CARE(20%)
8
HEALTH CARE SPENDING
(65%)
SOCIAL SERVICE SPENDING
(35%)
InvestmentMismatch
Courtesy of Elizabeth Bradley
Reconciling the clinical perspective with a broader community perspective
Community:
Public Health, Social Services
sectors
Health Systems: Hospitals, ACOs,
Health Plans
Clinical Practices: Primary Care
Medical Homes, Specialty Care
Subgroups of Patients:
Panels, Racial/Ethnic
groups, patients with specific
chronic diseases
Based on Kassler et al. N Engl J Med 372; 2015
Clinical Practices
• Population-based approaches:– considering what happens between visits– using registries and tools to improve preventive care– addressing health disparities by including social, economic,
and cultural factors– referring patients to a wider range of community services
• Supportive strategies:– Medical homes and care management payments– Linking practices and patients to community supports– Practice support (Transforming Clinical Practice Initiative)– Community Health Workers - translation, appointment
scheduling, referrals, and transportation
Delivery Systems
• Population-based approaches:– Assessing community health needs
– Investing community benefit dollars
– Collaborating with other organizations to support nonmedical services delivered in community settings
• Supportive Strategies:– Performance based alternative payment models
(e.g. ACOs) incentivize investments
Health Plans
• Medicaid and Medicare contracts afford greater flexibility than FFS to pay for population services
• Some MCOs cover bicycle helmets, car seats, participation in the YMCA’s Diabetes Prevention Program or March of Dimes Baby and Me Tobacco Free program
Medicaid Managed Care
Positively Impacting Social Determinants of Health: How Safety Net Health Plans Lead the Way June 2014
Leveraging Medicaid contracts through sponsorships,
grants, and partnerships to invest in:
• Housing support,
• Employment initiatives,
• Literacy programs,
• Services for overcoming food insecurity.
Communities / States
• Medicaid
– Historically covers many non-medical support services
– Waivers & Demos provide additional opportunities to invest in upstream strategies (Vermont waiver)
• State Innovation Models
– Use multiple levers for health systems transformation
– Population health plans
• Accountable Health Communities
Accountable Health Communities Model Intervention Approaches
• Track 1: Awareness – Increase beneficiary awareness of available community services through information dissemination and referral
• Track 2: Assistance – Provide community service navigation services to assist high-risk beneficiaries with accessing services
• Track 3: Alignment – Encourage partner alignment to ensure that community services are available and responsive to the needs of beneficiaries
Looking ahead: MACRA
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
is a bipartisan legislation signed into law on April 16, 2015.
• Repeals the Sustainable Growth Rate (SGR) Formula
• Changes the way that Medicare rewards clinicians for value
over volume
• Streamlines multiple quality programs under the new Merit-
Based Incentive Payments System (MIPS)
• Provides bonus payments for participation in eligible
alternative payment models (APMs)
CMS has adopted a framework that categorizes payments to providers
Payments are based on volume of services and not linked to quality or efficiency
Category 1:
Fee for Service – No Link to Value
Category 2:
Fee for Service – Link to Quality
Category 3:
Alternative Payment Models -- Built on Fee-for-Service Architecture
Category 4:
Population-Based Payment
At least a portion of payments vary based on the quality or efficiency of health care delivery
Some payment is linked to the effective management of a population or an episode of care
Payments still triggered by delivery of services, but opportunities for shared savings or 2-sided risk
Payment is not directly triggered by service delivery so volume is not linked to payment
Clinicians and organizations are paid and responsible for the care of a beneficiary for a long period (e.g., ≥1 year)
Source: Rajkumar R, Conway PH, Tavenner M. CMS ─ engaging multiple payers in payment reform. JAMA 2014; 311: 1967-8.
Lessons Learned: ACOs
• Demographics vary …– Urban/rural, large/small, HIT, populations served
• ... But culture similar– Focus on value & population perspective before
started ACO
– Emphasis on strengthening primary care(e.g. built on integrated medical home)
– History of coordination across sites of care(e.g. leveraged pre-existing relationships/focus on transitions)
– Strong clinician leadership / engagement
– Familiarity with data
Strategies for Sustainability
• Embed population health
– Value-based payments (MIPS metrics and incentives)
– Advanced APMs
• Support infrastructure development
• Partnership, collaboration and alignment across sectors
• Lessons learned from model testing
Hospitals’ Role in Population Health:
• To retain tax exempt status, non-profit hospitals must:– Conduct “community health needs assessment” every 3 yrs
– Adopt implementation strategy to meet the community health needs identified through the assessment
• Community Building. IRS-approved activities:– Leadership development / training for community
– Community health improvement advocacy
– Physical improvements and housing
– Coalition building
– Economic development
– Community support
– Environmental improvement
– Workforce development
Next generation models?
• Incentives for cross-sector collaboration
– CHNA, Community Building
• Risk adjusted payments for poverty
• Community incentive payments (e.g. tobacco)
• Social Impact Bonds
Challenges
• Fiduciary constraints on payers
– Funding non-medical services & upstream approaches
– Funding services for non-beneficiaries
• Scale-up from testing to implementation
– Time horizon and actuarial standards
• Provider scope of practice and accountability
• Measurement and data infrastrucure
Policy – Related Research Priorities
• Paucity of effectiveness data on psychosocial interventions – associated culture of resistance to evaluation
• Behavioral economics
• Emerging role for local public health agencies
• Practice infrastructure to manage populations
• Measurement
• Health disparities
• Collaboration and consolidation