Published on March 10, 2014
Division of Population Health Management Partners Approach to Meeting the Healthcare Cost Challenge Timothy Ferris, MD, MPH SVP, Population Health Management, MGH, MGPO and Partners HealthCare Nuffield Trust Health Policy Summit 2014 March 6, 2014
Division of Population Health Management What we’re facing… Constraining the growth of healthcare costs is a national priority Involvement of physicians through changed incentives is unavoidable PPACA - the imperative will persist even if the specifics change The market is using a similar play book – closed networks, budget-based risk, cost sharing, restriction of choice – and this may generate the same backlash as 1990s managed care era But... The economy is much worse Government is proactive (3.6%) Rate of change is slower (caps on increases, not cuts) And we have… Better health IT and data for population management Strategies and tactics that we know will improve care and reduce costs 2
Division of Population Health Management Implications for providers Our focus should be on reducing medical expense trend to as close to the rate of general inflation as we can We want to be part of the solution This means taking financial risk for costs of care Shared savings (Pioneer ACO), bundled payments, global payments Partners increased ability to care for populations of patients Successful CMS Demo, increasing evidence for other tactics Universally adopted EHR Challenges 1. We need tactics that will be successful under any new payment model 2. How to make external incentives meaningful to our physicians 3. Moving at the right pace Too fast: we will lose the docs in the rush to implement – MDs attitude often creates the patient's attitude (managed care backlash) Too slow: will mean not succeeding under the contracts and worsening the regulatory environment 3
Division of Population Health Management What is an ACO? An organization that agrees to share the financial risk for the care of a defined population Shared financial risk = rewarding providers for reducing medical spending by giving them a share of the net cost savings; may also include financial penalties for cost increasing above benchmark Defined population = every primary care patient whose insurer has signed a risk contract with that provider, regardless of where they receive care Source: Leavitt Partners Center for Accountable Care Intelligence at http://healthaffairs.org/blog/2014/01/29/accountable-care-growth-in-2014-a-look-ahead/ Total Accountable Care Organizations by Sponsoring Entity Total = 606 4
Division of Population Health Management Evolution of ACOs Estimated Accountable Care Lives in Public and Private ACOs* Accountable Care Organizations by State* 18.2m covered lives compared to 13.6m at end of 2012 •More than half of the US population (52%) live in primary care service areas served by ACOs, approximately 28% live in areas served by 2 or more ACOs.** •Los Angeles, Boston, and Orlando, have the most ACOs in the nation.* In Boston, ACOs care for more than 60% of patients.*** *Leavitt Partners Center for Accountable Care Intelligence at http://healthaffairs.org/blog/2014/01/29/accountable-care-growth-in-2014-a-look-ahead/ **http://www.oliverwyman.com/media/ACO_press_release(2).pdf ***http://www.acpinternist.org/archives/2013/07/acos.htm 5
Division of Population Health Management Background on Partners HealthCare Partners HealthCare (Partners) Integrated delivery system in Boston MA, includes two AMCs Massachusetts Hospital (MGH) Brigham Women’s Hospital (BWH) Partners became a Pioneer ACO, January 2012 Includes community and specialty hospitals, a physician network, home health and long-term care services, and other health-related entities 615 PCPs 76,000 patients 6
Division of Population Health Management Enhanced access to specialty services The path we’re traveling at Partners 7 Pressure to reduce cost trend New contracts with risk for trend Internal Performance Framework Investment in Population Management Infrastructure Changes to Partners org structure Partners in Care (PCMH & care coordination for high risk patients) Sustained cost trends near GDP Implement new local incentives/compensation Network Affiliations 1 2 3 New relationships with community hospitals and doctors 4
Division of Population Health Management Our new contracts…almost 2 years in Lives under the Accountable Care Model Medicare Commercial Pioneer Accountable Care Organization Elderly population, care management central to trend management Alternative Quality Contract (AQC) Younger population, specialists critical to management 21 Medicaid NHP Population with significant disability, mental health, and substance abuse challenges 3 Self Insured Partners Plus Commercial population, but savings accrue directly to Partners, and improves our own lives 4 Covered lives: ~80kCovered lives: ~25KCovered lives: ~350KCovered lives: ~75k Partners currently manages roughly 500,000 lives in various accountable care relationships 8
Division of Population Health Management Priority programs 9 Priority Population Health Management Programs Primary Care •Patient Centered Medical Home (PCMH), including especially access •High risk care management •Mental health Specialty Care •Referral management •Virtual visits •PrOE/PROMs •Bundles Care Continuum •SNF networks •Mobile observation units •Urgent care Patient Engagement •Shared decision making •Virtual patient communities •Customized risk and educational materials Infrastructure •IS, analytics •Program management
Division of Population Health Management Virtual visits and technology tools 10 Email Video Conferencing Telephone Text Messaging Electronic Curbside Technology Pediatric Virtual Video Pilots •Follow up visits in the home for children and adolescents with Autism, ADHD, Substance Abuse, etc, •Post-acute burn consults for patients at Boston-Spaulding Rehabilitation Hospital •Parents of patients in the PICU virtually attend rounds with care team and their child 35 48 313 Pediatrics Burns Center Child and Adolescent Psychiatry 17 2 0% 20% 40% 60% 80% 100% Cardiology Resulted in Visit Curbside Consult Performed Cardiology Curbside Consults* *Start of pilot Jan 2014 •Referring physicians can quickly contact a cardiologist in the outpatient setting and receive recommendations in the electronic medical record •Offers referring providers and patients an alternative to waiting for in-person cardiology appointments
Division of Population Health Management Chen, A. H., Kushel, M. B., Grumbach, K., & Yee, H.F. (2010). Practice profile:.A safety-net system gains efficiencies through ‘eReferrals’ to specialists. Health Affairs (Millwood), 29(5), 969-71. Why is this important? Assessing the appropriateness of referrals prior to scheduling may have a positive impact on our efforts to Reduce avoidable office visits Increase access for our sickest patients Increase experience coordination and efficiency of specialist visits through pre-visit planning Approaches for managing referrals 11
Division of Population Health Management Idealized patient journey through an episode of care that includes a procedure Patient Problem Assess Appropriateness Criteria Assess Risk Schedule OR Procedure Recovery Physician encounter Possible Need for Procedure Shared Decision Making Pre- Procedure Testing Tier 1, 2 Outcome Measures Tier 3 Outcome Measures Personalized Consent Form Informed Consent Tier Category Examples 1 Health status achieved Survival and degree of health recovery 2 Process of recovery Time to recovery and return to normal activities 3 Sustainability of health Sustained recovery and recurrences, including long term consequences of therapy Outcome measures hierarchy: 12
Division of Population Health Management Appropriateness Data Repository Procedure Scheduling PrOE Appropriateness tool Public Reporting PCI, CABG, Vascular, Harris Joint Internal Performance Dashboards Billing and Prior Authorization RPM, RPDR, CDR, EMPI Pre- populated data fields (NLP search) INPUTS OUTPUTS Personalized consent form Existing registries LMR, OnCall Data storage EMR Appropriateness Indications & Decision support Measurement & analysis of appropriateness and outcomes inform guidelines and indications in real-time Data passback to registries (Web service) Copy of appropriateness results placed in LMR and CDR EHR note created PrOE: Inputs and outputs 13
Division of Population Health Management 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% CAS CEA CABG Diagnostic Catheterization Not in PrOE In PrOE Percent of Procedures with a PrOE Assessment Appropriateness Scores for Diagnostic Catheterization by Month 2014 Procedures •Incisional Hernia •Prostate Biopsy •Gastric Bypass •Valve Repair •Lumbar Fusion •Peripheral Vascular Disease Therapies 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Aug Sept Oct Nov Dec Rarely Appropriate Maybe Appropriate Appropriate Median hospital-level inappropriateness rate is 28.5%** **Hannan, EL, et al. Appropriateness of Diagnostic Catheterization for Suspected Coronary Artery Disease in New York State. CIRC INTERVENTIONS. January 28, 2014. 113.000741n=745 n=8986 Median hospital-level inappropriateness rate is 28.5%** Appropriateness Scores for Diagnostic Catheterization at MGH vs. NY Cardiac Database ** 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% MGH NY Cardiac Database Rarely Appropriate Maybe Appropriate Appropriate Results to date 14
Division of Population Health Management Patient Reported Outcome Measures (PROMs) 15 Outcomes that matter to patients: direct collection of information from patients regarding symptoms, functional status, and mental health. Why PROMs? Improves care of individual patients through better monitoring and improved responsiveness Improves system-wide care by measuring/improving the right outcomes – those that matter most to patients How are PROMs collected? Patients enter information into an electronic platform using iPads, patient portal, or the web PROMs will be implemented for all sites and diagnoses Current Conditions include: Coronary Artery Disease: CABG, Cardiac Catheterization Osteoarthritis Valvular Disease Diabetes Depression Additional conditions planned for 2014
Division of Population Health Management What does PHM cost? Total Cost PHM Programs (Annual Operating & 1x expense) PHM Cost as a Percentage of External Risk TME (At 2017 Steady State Run Rate) PHM Program Costs as a Percentage of External Risk TME only Total Costs as Percentage of External Risk TME only 4.96% 4.96% 16
Division of Population Health Management What is the ROI? $0 $50 $100 $150 $200 $250 2015 2016 2017 Total PHM Acceleration Cost Savings from External Risk Savings from full IPF Savings from full panel (Loyalty Cohort) PHM Program Savings Relative to Total Operating Program Costs (Assumes Steady State in 2017) •Two-thirds of PHM acceleration costs fund programs that generate TME savings •Remaining funds support infrastructure, innovative pilots (i.e. SNFist), community specialist engagement that accrue minimal or difficult-to-measure savings 17
Division of Population Health Management Key Challenges Overlapping programs and contracts (e.g. Chronic Disease Demo) Timely data and useful performance measures (CMS delays with delivery of prospective patient information) Transition costs—establishing the EHR infrastructure Funding the infrastructure (no grant funds) Intersection between the multiple Boston area ACOs Notification management ED notification Discharge notification Sharing of best practices between colleagues Learning what works and providing timely feedback for policy changes/enforcements to CMS Limited leverage when patients seek covered services that provide little or no benefit Time to ROI not consistent with duration of contracts 18
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