doing care differently: the journey to a healthier kentucky innovate, accelerate, collaborate 2014...
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Doing Care Differently:The Journey to a Healthier Kentucky
Innovate, Accelerate, Collaborate
2014 Howard L. Bost Memorial Health Policy ForumSeptember 16, 2013
“Health is a state of complete physical, mental and social well-being and not merely
the absence of disease or infirmity.”
Health Impact Pyramid (CDC)Factors that Affect Health
Source: Georgia Department of Public Health; Centers for Disease Control and Prevention
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The Institute for Healthcare Improvement (IHI)The Triple Aim
U.S. health care system is the most costly in the world
Yet, we get the worst outcomes of nearly any industrialized country, even when adjusting for age and income
And, Kentucky is among the lowest U.S. states for outcomes, according to the America’s Health Rankings
Source: Georgia Department of Public Health
http://www.ihi.org/Engage/Initiatives/TripleAim/pages/default.aspx
Population Health
Per Capita CostExperience of Care
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The Healthcare Landscape
“Digital Health feels like the PC industry in the early ’80′s.”
John Sculley – Former Apple and PepsiCo CEO
“I think the extreme complexity of medicine has become more than an individual clinician can handle. But not more than teams of clinicians can handle.”
Atul Gawande – Surgeon, Author, Journalist
“I don’t blame anybody – they’re just doing what makes sense and we have to change what makes sense.”
Don Berwick – Former CMS Administrator
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Perspectives: Healthcare is a different industry than it used to be
The Healthcare Landscape
The U.S. health market requires greater flexibility and insight than ever before. Leaders increasingly need expert advice to make sound decisions in today’s climate.
Regulatory Environment
Aging Population
Evolving Payment Models
State Budget Crises
Unprecedented
Environmental Change
Consumerism
Comparative Transparency
Workforce Challenges
Emerging Technologies
Quest for Value
The Market Is Complex And Evolving
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The Healthcare Landscape
Demographics Healthcare Reform
Population GrowthPopulation AgeingChronic Conditions
Economic Pressure
GovernmentsEmployersMarket Competition
PPACA (US)Other global reform (e.g., GER)ARRA, HITECH for EHR
Aggregation, Storage and AnalyticsPooling/Open DataData Center Capacity
TelemedicineWireless SensorsRemote Patient MonitoringApps/Social Media
GenomicsTargeted TherapeuticsPersonalized TreatmentsPharma Firms Competing to ‘Own The Disease’
Payer-Provider Integration Incentive AlignmentRisk Shifting
Consumer EngagementValue Based Benefits Wellness/Preventative Programs
Population Models (e.g., PCMHs, ACOs)Condition Oriented Models (COEs, DM programs)
Key Drivers
Business Model
Enablers
Convergence Care Model RedesignConsumerism
Technological
Enablers
‘Big Data’ Personalized MedicineMobility
Various economic, technological, regulatory and social factors are pushing the industry in new directions, creating problems that never before existed.
Drivers and Enablers of Change
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The Healthcare Landscape
The Past
Employers, payersRisk
Reimbursement
Service/volume-based
2000 2010 2015 2020
Delivery Hospital-based, expert/specialist driven
Community/retail-based, team driven
Information Siloed, static, paper-based
Treatment One-size-fits-all, volume-based
2005
Personalized, value-based
Networked, dynamic, digitally-based
Performance/value-based
Providers, patients
The Future
Physicians are in the unique position to help shape the industry’s future.
Healthcare transformation has afforded physicians unprecedented opportunities to shop their medical degrees to firms tasked with solving today’s issues.
Where is the industry going?
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Healthcare Reform
ISSUESHigh cost to families
■ Average insurance $14,000/ family and has doubled in last 9 years
■ Aging population with more health problems
High Cost To Federal Government
■ Fastest growing segment of federal budget
Holes in coverage
People who need insurance most often turned down by preexisting conditions, lifetime limits, small business costs
1 in 7 had no insurance or under insured
Health care organizations should take offensive and defensive strategic responses to these drivers:
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Healthcare Reform
ISSUES
SOLUTIONS
Insurance Reforms (no lifetime limits, limit preexisting conditions)
Adjustments to Government programs (Medicaid expansion, Medicare Drug program)
Health Insurance marketplace / exchanges (more competition)
Insurance Mandate - required insurance coverage (32 million new insured people)
Health care organizations should take offensive and defensive strategic responses to these drivers:
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Healthcare Reform
ISSUES
SOLUTIONS
IMPACT
$200 Billion savings over 10 years (2% of Budget and 3% of overall Healthcare spending)
DON’T IMPACT DEFICIT. Must be paid from savings from Healthcare Providers, Medicare Insurers with less reimbursement and new taxes on healthcare companies and individuals
$124 Billion in potential additional savings over 10 years
Source: http://obamacarefacts.com/costof-obamacare.php
In 2012 U.S. health care spending increased 3.7 percent to reach $2.8 trillion, or $8,915 per person
Health care organizations should take offensive and defensive strategic responses to these drivers:
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Healthcare ReformHealth care organizations need to take offensive and defensive strategic responses to these drivers.
Quality reporting• Pay for performance• Regulatory influence• Transparency/data sharing
New SustainableBusiness Model
Federally mandated programs that focus on quality and patient
safety
2013: Administrative simplification
2014: Exchanges
open to individuals and small
employers
2011: Minimum
medical loss ratio and rebates
2017: Exchanges
open for large employers
2012: Medicare
Advantage STAR Quality-
based payments
Fall 2011: CMS ACO
application period
2013: Episode-based payment pilots
begin
2012: CMS ACOs
begin
Value-based incentives and
avoidable readmission
penalties
2015: HITECH penalties
begin
HealthcarePlans
HealthcareProviders
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The Healthcare Journey
Are we on diverging or converging paths?
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Innovate
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Heath System Transformation
Acute Care System 1.0
---
Episodic Non-IntegratedCare
Coordinated SeamlessHealthcare System 2.0
---
Outcome AccountableCare
Community IntegratedHealthcare System 3.0
---
Community IntegratedHealthcare
Episodic health care Lack integrated care networks Lack quality and cost
performance transparency Poorly coordinate chronic care
management
Patient/person centered Transparent cost and quality
performance Accountable provider networks
designed around the patient Shared financial risk HIT integrated Focus on care management
and preventive care
Healthy population centered Population health focused
strategies Integrated networks linked to
community resources capable of addressing psycho social/ economic needs
Population-based reimbursement
Learning organization capable of rapid deployment of best practices
Community health integrated E-health and telehealth
capable
Overview
Source: Neal Halfon, UCLA Center for Healthier Children, Families & Communities 15Copyright © 2014 FTI Consulting, Inc.
New Business Models
Patient Protection and Affordable Care Act of
2010 encourages providers to take
responsibility for the cost and quality of care and enables the formation of
ACOs.
Shared-Savings ProgramCenters for Medicare and Medicaid
Services (CMS) created shared-savings program for accountable
care organizations (ACOs)
ACOsGroups of hospitals and doctors
committed to reducing the cost and improving the quality of care
Accountable Care Organization
Clinically Integrated Network
Other
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Level 1 - In Patient Acute CareLevel 2 - Post Acute Care
Level 3 - Chronic Condition Management
Level 4 - Population Health Management
Quality Over Quantity (Value
over Volume)Assuming increased financial and clinical
accountability
New Business Models
Accountable Care
Organization (ACO)
Value-Based Care(VBC)
Care Coordination
The ACO is the centerpiece of a
Clinically-Integrated Network Model
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Volume (expanding exponentially) social media, household appliances, automobiles, stop lights blood pressure cuffs, smart scales, diabetes monitor, exercise
equipment
Velocity (rate at which volume is being generated) From the beginning of time to 2003, we produced 5 exabytes
(10006) of data. From 2003 to 2012 we produced 2.7 zettabytes (10007), or 500x
more data. From 2012 to 2015 we will produce three times more data than
between 2003 and 2012.
Variety (types of data being produced) documents, data (stock ticker), photos, audio, video, 3D models,
location data, unstructured data
Big Data, Big Impact
Traditional data management no longer works.
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The volume and quantity of data needed to analyze population health in hospitals and health systems has not existed historically in healthcare.
Healthcare organizations have not invested in data and statistical analysis-based competencies• Data quantity, prediction, data
analysis population sets, statistics, insurance actuaries, etc.
Data Driven, John Morrissey, Hospitals & Health Networks, 2013*McKinsey Global institute
Is Big Data Worth The Effort?$300 billion potential impact in exploiting Big Data in healthcare*
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= FTC & CLIO Payer Requirement (2014)
= At-Risk Population Management – Risk Stratification Requirement (Timing TBD)
Improving Healthcare Through Enhanced Technology
PatientEngagement/ Outreach
• Patient Portal• Patient Education• Mobile Applications• Automated Reminders• Response Tracking• Patient Assessments• Wellness Programs
Care Management/ Coordination
• Patient Registries• Care Gap Reporting/
Alerts• Visit Planner/Patient
Summary• Care Transitions &
Coordination • Clinical Decision
Support• EMR Integration
Clinical Data Capture& Analytics
• Data Repository• Claims Data Handling• Terminology Mapping• Physician Score-
carding• Existing Quality
Measures• External Benchmarking• EMR Interfaces• Clinical Data Handling
Population RiskStratification/ Management
• Predictive Risk Models• Care Gap Reporting• Customizable Filters• Performance
Reporting• Provider Dashboards
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Accelerate
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■ Operational Performance – generally dealing with status quo acute hospital care and how to cut costs and improve revenue
■ Clinical Quality – movement towards outpatient home care, clinical outcomes, patient preferences, and national campaigns, such as Choosing Wisely
Comprehensive Quality ImprovementTwo Fundamental Optimization Pathways
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Comprehensive Quality Improvement:
Time, Complexity, & Difficulty
Valu
e, R
isk
& R
ewar
d
V
Operational Performance Optimization
Revenue – Revenue IntegrityLabor – Span of Control, HRSupplies – Standardization & UtilizationTech – EHR OptimizationClinical – LOS, Utilization, VariabilityPhysicians - Enterprise & CARTS
Revenue – AR & BillingLabor – BenchmarkingSupplies – GPOs & PricingTech – HIS + Bolt-onsClinical – Effectiveness
Revenue – Patient Access, DenialsLabor - Process InnovationSupplies – Purchased ServicesTech – EHR ImplementationClinical – Value-Based Purchasing(e.g., Readmissions)
Revenue – Call Center, Hospital & Physician IntegrationLabor – Shared ServicesSupplies – Strategic RelationshipsTech – Business IntelligenceClinical – Integration/ Risk Contracting/ Population Health, Reinventing Care DeliveryPhysicians – Network DevelopmentScale - Merger/ IntegrationCulture – Learning Organization, Patient Empowerment
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Clinical Quality Improvement:
Three Core Metric Objectives
Functional Status
Morbidity
Rate
MortalityRate
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Clinical Quality Improvement:
Impact Evaluation Metrics
QualityCare gap closurePeer reviewCare pathway compliance
Outcomes/Health Status
Potentially preventable admissions (PPAs)
ReadmissionsOther potentially
preventable events
Satisfaction/Quality of Life
Patient satisfactionProvider satisfactionMD/staff retention rates
Process/Behavior Change
Health Risk Assessments completed
ED wait timesSmoking CessationBMI Reduction
Efficiency/RiskAcute Length of Stay by
DRG/CPT, etc.Effective coding for
Population Health Management
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Our Nation: Nutrition, Physical Activity, and Obesity
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Rates of obesity are high in all states among adultsProgress in Nutrition, Physical Activity, and Obesity
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Progress in nutrition, physical activity, obesity, and food safetyProgress in Nutrition, Physical Activity, and Obesity
From 2008-2011, obesity among low-income preschoolers declined in 19 of 43 states and territories studied.
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Our Nation: Tobacco Use
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Adult smoking rates vary widelyNearly 3x higher in some states than in othersTobacco Use
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Many states have passed smoke-free laws in worksites, restaurants, and barsTobacco Use
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Collaborate
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The goal of population health management is to keep a patient population as healthy as possible, minimizing the need for expensive
interventions.
Proactive preventive and chronic care to all of a patients during and between encounters
Manage high-risk patients to prevent them from becoming unhealthier and developing complications
Use of evidence-based protocols to diagnose and treat in a consistent, cost-effective manner
Population Health
Accountable Care
Patient Registries
Care Teams
Disease Manageme
nt
Patient-Centered Medical Home
Coordinated Care
Population Health – The First Line of Defense
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Population Health:
Transitioning to Value is a Huge Change
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Current View30 Patients per Day14 have Chronic ConditionsUnknown Health RisksOffice Visits too short for coaching
New Population View2500 Patient Population900 have Chronic Conditions1100-1250 have Moderate/High Health RiskCare Teams leveraged by HIT
Volume-Based/Episodic Care Value-Based/Continuous Care
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Population Health:
A Model
CommunityHealth
ChronicDisease
Payment Rewards
Behavioral
Health
Health vs.Care
PublicHealth
PublicSafety
K-12Education
Community
Investment
Ref.: Truman Medical Centers
Population Health
Dynamics:
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Population Health
Interactive Stakeholders:
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PolicyMakers/
Advocates
Patients/Community
Politicians
ClinicalProviders
Pharma/Medical Devices/Vendors
Patient/Communi
tyAdvocate
s
Public Health
Agencies
Educational
Systems
Purchasers
Payers
HealthSystems
Public Health and Healthcare Opportunities to Work Together on Population Health
Source: Georgia Department of Public Health
Linking the Medical Home, Public Health Services and the Hospitals
Quality Improvement
Community Engagement
Shared Health Assessment and Health
Improvement Planning
Care Extension and Case
Management
Designing Billable
Community-Clinical
Interventions
1 2 3
4 5 6
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Logic will get you fromA to B
Imagination will take you everywhere
- Albert Einstein
Doing Care Differently: Journey to a Healthier Kentucky
A Final Thought
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Prepared by:
Phillip L. Polakoff, MD, M.Env.Sc., MPH Senior Managing DirectorChief Medical ExecutiveHealth SolutionsFTI [email protected]
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