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9/13/2013
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Population Management at Crystal Run Healthcare
Jonathan F. Nasser MD
Co-Chief Clinical Transformation Officer
Crystal Run Healthcare
AMGA CMO Council
September 2013
About Crystal Run Healthcare
Physician owned MSGP in NY
State, founded 1996 300 providers, 15 locations JV ASC, Urgent Care, Diagnostic
Imaging, Sleep Center, High Complexity Lab
Early adopter EHR (NextGen®) 1999
Accredited by Joint Commission 2006
NCQA-designated Level III PCMH 2009, 2012
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About Crystal Run Healthcare ACO
Single entity ACO
NCQA ACO Recognition Level 2
MSSP April 2012
4 Private Payers 2013
MSSP
10,000 attributed beneficiaries
82% primary care services within ACO
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Healthcare Edition
Outline
Definition
Population Management on the Frontlines
PCMH
Care Management
Population Management behind the scenes
Registries
Claims Analysis / Predictive Modeling
Transitional Health
Lessons Learned / Next Steps
Discussion
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What is Population Management?
Health outcomes of a group of patients
Information-powered clinical decision making
Primary Care led clinical workforce
Managing risk
Identifying targeted cost savings opportunity
Lowering health care spending for managed populations
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Population Management PCMH
Medical Neighborhoods
Embedded Care Managers
Value Based Care Block Time Gaps Analysis
Process Improvement
Hotspotting
Medical Home Meetings Process Improvement
Transparent Data Sharing
Hotspotting
Population Management PCMH
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Population Management PCMH
Population Management High Risk Care Management
9 Care Managers
Panel Statistics
Criteria
Hospitalization (excluding OB, surgery, Peds)
CHF, COPD, DM2, CAD
High risk Urology, Orthopedics, Breast
Claims based Risk Identification
Provider Referral
Workflow
Evolution
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Population Management Focused Registries
Mammography Organizational gaps analysis
Pediatric Asthma / DOH pilot Admission, ER, steroid use
Hgb a1c > 9 work rounds
Next Up: Colon Cancer Screening
Population Management Claims Analysis
Identification of Utilization Patterns
Diagnostic Tests
Diagnosis
Facilities
Inappropriate Care Sites
Identifying High Risk Patients
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Population Management Claims Analysis – internal analytics
Medicare Claims
Lab Spend: #1 TSH, #11 Free T4
$5 million/ year Rehab
Top 5 facility dx: rehab, sepsis, ESRD, pneumonia, CAD
Top 5 procedures: colonoscopy, arthrocentesis, TKR, vein ablation, THR.
Population Management Claims Analysis
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Population Management Claims Analysis - Hotspotting
Name CCHG EBM Compliance Concurrent Risk Score Prospective Risk Score Cost in Attributed Months
xxxxxxxx Active cancer N/A 31.52 32.64 77145.75
xxxxxxxx
Severe rheumatic & other connective tissue disease 100% 10.72 18.09 70506.98
xxxxxxxx Renal failure - post transplant N/A 38.3 15.53 28621.05
xxxxxxxx COPD N/A 40.16 11.47 13391.26
xxxxxxxx Active cancer N/A 51.43 11.37 71139.34
xxxxxxxx
Hypertension (Includes stroke & peripheral vascular disease) 14% 17.91 10.8 60570.53
xxxxxxxx Active cancer N/A 28.11 10.74 29312.11
xxxxxxxx Major psychosis 83% 16.44 10.6 45876.6
xxxxxxxx Active cancer 100% 12.36 9.07 31825.42
Population Management Reducing Avoidable Costs
Interventions
Education
Variation Reduction: UTI
Prehab
Innovation Contest – ER utilization
SNF Summit
Hotspotting
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Transitional Health CARETEAM
Community and Residential Extenders for
Transitions, Evaluation and Management
Goal: 10% reduction in admissions, readmissions and length of stay
Focus: Medicare, High Risk Conditions
CARETEAM criteria for initial home visit
Medicare, PCP in ACO
COPD, CHF All hospitalization and urgent care visits
Pneumonia with co-morbidities All hospitalization and urgent care visits
Diabetes Hospitalizations for DKA, new onset or multiple admissions
Urgent Care visits for hyperglycemia
Complex Co-morbidities
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CARETEAM criteria for second home visit
Two of the following:
Poor self management skills
New diagnosis
Poor support / lives alone
Poor medication compliance
Age > 65
Mental Illness or Poor Cognitive status
Clinically unstable during home visit
Complex co-morbidities
PCP f/u
+
2nd home
visit
PCP f/u
3-4 days
Intervention
CARETEAM process map
Indication
Home Visit
Care Man./
Transitions
Coordinator
Stable At risk
Home
Visit
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CARETEAM outcome of visits (n=818)
Nu
mb
er o
f Vis
its
CARETEAM Medicare 30 day readmissions
Embedded Care
Manager Home Visits
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CARETEAM Telehealth
Reducing Admissions and Readmissions
Evidence
Telemonitoring
Devices
IVR
Patient Identification
Case-Control Evaluation
CARETEAM Telehealth
Patient Eligibility
Telehealth Responsive Conditions: COPD, CHF, DM2, hospital discharge
Patient Identification:
Provider Referral,
Disease Severity (FEV1<1L, EF < 40%, Hgb A1c>11),
Excess Utilization
Exclusions: Refusal, Inability to participate (cognitive, mental health), Infectious Reasons
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Telehealth Enrollment Algorithm
Eligible
PCP
Approval
Control No
Yes
Exclusions ?
COPD
CHF
DM2
Device
Hospital
D/c
IVR
Yes
Y
e
s
No
How Are We Doing? Medicare Beneficiaries
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Population Management Lessons Learned
Significant preparation prior to affecting change
Balance between front line intervention and organizational analytics
Frequent feedback and assessment needed
Power of Claims
Questions