HBCH – Local HealthSystem Strategies

Shawn Griffin, MDChief Quality and Informatics

Officer, MHMDOctober 8, 2015

Major Trends

• Houston Price Pressures Increasing• Health Systems Expanding Into Growing

Markets• Payer, System, and Group Consolidation

Changing Existing Relationships• Accountable Care Organizations Growing,

but Not All Systems Buying In• Primary Care Affiliations Expanding

3

Traditional Healthcare –A Flawed ModelHow the industry has functioned

Physicians, hospitals, and insurers working insilos

Lack of data sharing across the functions thattouch the patient

Billboard Medicine - Management of a singleoccurrence, not the population

Patient engaged after becoming sick

Inadequate transparency and access to data

Lack of population management tools andcomprehensive data

Misaligned incentives between providers andinsurers

Disease and care management only aninsurer function

Little focus on systemic improvement

How it will have to function Willingness to depart from old models and

change roles of key players

New technologies enable data flows to allproviders wherever the patient presents

Focus on population health, prevention, andthe patient outside the health care setting

Proactive patient engagement

Transparent sharing of data among providersand between providers and insurer

Population management tools employed andinformed by data to give 360o view

Aligned incentives reward providers andhospitals for improved quality and cost

Providers and insurer collaborate on disease& care management to maximize impact

Investment in continuous improvement

3

Accountable Care =Healthier Population

4

QUALITY

COST

Doesn’t that soundsimple?

Doesn’t that soundsimple?

Evidence-based Utilization

A Very Basic Premise

5

HospitalsHospitals

MHMD MHHS

PhysiciansPhysicians

Houston Landscape

6

Physicians Hospitals AmbulatoryNetwork

Post Acute

Who you contract with “commoditizes” other parts.Who you contract with “commoditizes” other parts.

ACCOUNTABLE CARE ORGANIZATIONACCOUNTABLE CARE ORGANIZATION

Multi-specialtyGroups

Multi-specialtyGroups

MedicareAdvantage

Plans

Payers

HospitalSystems

HospitalSystems

MedicareAdvantage

Plans

How will we get there?

7

EducationCultural ChangeAligned IncentivesOrganizational StructureCommitment to Evidence Based Medicine Information

EducationCultural ChangeAligned IncentivesOrganizational StructureCommitment to Evidence Based Medicine Information

We Started Many Years Ago…

5 Key Strategic Inflection Points Clinical Programs Committees (CPCs) (2000) Clinical Integration (2005) The Physician Compact (2008) The Patient-Centered Medical Home

(PCMH)(2011) The Accountable Care Organization (ACO)

and Single Signature (2012)

8

Organization Timeline2010 20142000 2004 20122002 2006 2008 20112001 2005 20132003 2007 2009

FTC Consent Order

PQRI reporting

Order Sets

Crimson DevelopmentDiscovery of CI

Commitment to eCW

Data Analyst, Humana CI ContractBoard Restructure, MSSP ACO

CQIO, MHealth CI Contract

CPC Restructure, IPA PartnershipOrder Set Delegation

CI Bonus $

CI Bonus $

IPQS

CPRM, NCQA Certifications

MHMD Care Management

CI Bonus $Aetna ACO Contract

BCBS ACO ContractPediatric APP Contracts

Network Management

POC, APCP Contracts

Region MeetingsSupportive Medicine

Strategic Analytics, ScheduleNow

DocbookMDReferral Center, Life In Balance

ACO Service Line ProjectsCI Bonus $

MSSP Bonus$

CompactCompact

CPCsCPCs

MH ACOMH ACO

PCMHPCMH

CPCsClinicalIntegrationClinicalIntegration

Authority of the CPCs

Delegation from the health system Protocols (creating and measuring EBM practices and order set

templates)

Performance (setting and monitoring progress against establishedquality standards and protocols)

Products (drives the standardization of vendors, formularies, supplychain decisions)

Payment (Pay for performance goals, co-management agreements,ACO project metrics, PCMH elements)

Projects (ED to ED transfer policy, CT scanning in pediatric headtrauma, standardized order sets in Observation units, serviceline, credentialing and privileging standards)

Program Rationalization (Consolidation and concentration of clinicalservice delivery – i.e. open heart and joint programs)

10

Iatrogenic Pneumothorax

MH SoutheastHospitalMH Southeast hospital

20 MonthsZero Iatrogenic Pneumothorax

Ultrasound MandatoryUltrasound Mandatory

MH SoutheastHospitalMH Southeast hospital

20 MonthsZero Iatrogenic Pneumothorax

Ultrasound Mandatory

514 CPCRecommendations

in 2014

Clinical Integration (2005)

Participating physicians must participate• Selecting quality measures• Reporting performance• Determining performance targets (setting realistic

goals)• Participate in committee work, performance

feedback, and quality improvement activities• Time, effort and IT infrastructure all required

Those who do not participate even afterremediation, must be removed!

MHMD Compact

13

BUT WHAT WAS MISSING?WHAT ABOUT OUTPATIENT?

14

DiscountsLiability InsGroupPurchasing

SingleSignatureContracts

Clinical Integration | Accountable CareOrganization

Clinical Integration | Accountable CareOrganization

Physician TrainingHCC

DocumentationICD-10CMEs

MU UniversityPhysician University

Practice TransformationEMR

Point of CareNCQA

Practice Assessment

PatientAccess

Patient Portal

Pt EngagementPatient EducationPt Engagement

Patient Education

Gap ReportsAt Risk/High Risk

Physician Report Cards

Supp MedicinePost Acute

Ambulatory ICU

UC/AHRetailClinics

Care MgmtDisease Mgmt

Health CoachesPreventive Care

The Patient-CenteredMedical Home (2011)

Informed Physician Better Care Great Experience

QualityInnovation

QualityInnovation

GNEProgram

DataClaims Files

EMR data Lab Rx

Technology

Primary Care Network>350 Adult & Pedi Physicians

16

West Region70 APCPs

Region Leaders – Dr. Ankur Doshi &Dr. David Reininger

SW Region76 APCPs

Region Leader – Dr. John Vanderzyl

North Region60 APCPs

Region Leader – Dr. Ken Davis

Northeast Region27 APCPs

Region Leader – Dr. Tejas Mehta

Central Region56 APCPs

Region Leader – Dr. Kevin Giglio

Southeast Region48 APCPs

Region Leaders – Dr. MaqsoodJaved & Dr. Adnan Rafiq

WHAT DID WE LEARN ABOUT OURPERFORMANCE AS A COST &QUALITY PROVIDER?

Putting Inpatient and Outpatient performancetogether when caring for whole populations…

17

Memorial Hermann

13%better

18%better

11%better

8%better

Aetna Commercial DataMemorial Hermann is more efficient than the market

Houston market

Inpatient Days/ 1000

Re-admission rates

Average length of stay

ER visits / 1000

208

236

5.1%

6.0%

3.5

3.9

180

164

Favorable PerformanceMetric Trends

18

by any other Name….

Accountable Care Organizations Affordable Care Act / Obamacare Population Health Clinical Integration Patient Centered Medical Homes And the ability to apply to become a

Medicare ACO participant

19

Along Came Health Reform

Memorial Hermann ACO (2012)

20

VA

Ps

Rat

e pe

r 1K

Ven

t Day

s

System VAPDo No Harm

Ventilator Associated Pneumonia

Source file date: 1/30/2013Generated: 1/30/2013 12:18:11 PM Reporting Months

produced by System Quality and Patient Safety

UCL = 3.50

Mean = 2.04

LCL = 0.58

UCL = 2.88

Mean = 1.23

UCL = 2.44

Mean = 0.95

UCL = 2.46

Mean = 0.64

Qtr 1Qtr

2Qtr

3Qtr

4Qtr

1Qtr

2Qtr

3Qtr

4Qtr

1Qtr

2Qtr

3Qtr

4Qtr

1Qtr

2Qtr

3Qtr

4Qtr

1Qtr

2Qtr

3Qtr

4Qtr

1Qtr

2Qtr

3Qtr

4Qtr

1Qtr

2Qtr

3Qtr

4

2006 2007 2008 2009 2010 2011 2012

0.00

2.00

4.00

6.00

Allowed for collaborative aligned incentives

programs between hospital and physicians

Relaxed fraud and abuse restrictions

Provided for safe harbors

Provided exclusive single signature capabilities

21

What Does an ACO Mean?

AND THE PAYERSRESPONDED TO OUR MODEL

22

Covered Lives (2015)

23

370,000+Covered Lives

370,000+Covered Lives

Aetna Whole Health (ACO) (26,000)Aetna Whole Health (ACO) (26,000)

Health Solutions Commercial(45,000+)

Humana Commercial (18,700)

United Medicare Advantage (8,800)

Aetna Medicare Advantage (5,800)

Aetna Commercial (85,000)Aetna Commercial (85,000)

United (45,000)*United (45,000)*

Humana Medicare Advantage (5,000)

CMS MSSP (ACO) (45,000+)

BCBS (90,000)*BCBS (90,000)*

*estimated.

Evolution of Partnerships

PhysiciansPhysicians HospitalsHospitals

MHMD MHHSHealth PlansHealth Plans

PAYERS

ARE WE MANAGING COST& IMPROVING QUALITY?

DID IT WORK?

25

PARTNERING WITHEMPLOYERS

26

Clinical Economics Improved

0 100 200

CT Scans and MRIs /1,000

High -Tech Radiology Visits /1,000

Impactable Surgical Bed Days /1,000

Impactable Medical Bed Days /1,000

Impactable Surgical Admits /1,000

Impactable Medical Admits /1,000

Impactable Admits /1,000

Effic

ienc

y M

etric

s

27ACO Network, YOY performance

27.1%lower

26.6%lower

28.3%lower

47.0%lower

5.7%lower

42.4%lower

47.8%lower

0%10%20%30%40%50%60%70%80%90%

100%

Asthma:Use of

appropriatemedications

Breastcancer

screening

Cervicalcancer

screening

Colorectalcancer

screening

Diabetes:Lipid profile

Diabetes:HemoglobinA1c testing

Aetna NationalAverage

Clinical Quality Improved

2014 MHMDPerformance

Better Cost and Quality forEmployers

Global Engineering and Construction Co.supporting Energy, O&G industry

29

Efficiency Results TARGET RESULT DELTA“Impactable” MedicalAdmissions/1,000 55.0 16.7 69.6%

Potentially Avoidable ER Visits/1,000 95.4 65.7 31.1%

High Tech Radiology Visits/1,000 170.3 149.0 12.5%

CT Scans and MRIs/1,000 66.3 60.5 8.7%

15%lower

20%increase

Enrollment 2014

2015

Medical Costs Target

Actual

BEST IN THE COUNTRY MSSPPERFORMANCE

30

MSSP Performance Year 1(18mo)

31

MSSP ACO State Total Savings ACO Share

Memorial Hermann AccountableCare Organization TX $57.83 M $28.34 M

Palm Beach Accountable CareOrganization, LLC FL $39.57 M $19.34 M

Catholic Medical Partners-Accountable Care IPA, Inc. NY $27.92 M $13.68 M

Southeast Michigan AccountableCare, Inc. MI $24.68 M $12.09 M

RGV ACO Health Providers, LLC TX $20.24 M $11.90 M

ProHEALTH Accountable CareMedical Group, PLLC NY $21.91 M $10.74 M

Triad Healthcare Network, LLC NC $21.51 M $10.54 M

WellStar Health Network, LLC GA $19.88 M $9.74 M

Accountable Care Coalition ofTexas, Inc. TX $19.10 M $9.36 M

MSSP Performance Year 2(12mo)

32

MSSP ACO State Total Savings ACO Share

Memorial Hermann AccountableCare Organization TX $52.93M $22.72M

Palm Beach Accountable CareOrganization, LLC FL $32.17M $14.46M

Physician Organization of MichiganACO MI $27.07M $12.08M

Oakwood ACO, LLC MI $19.07M $8.15M

Millennium ACO FL $17.49M $7.98MProHEALTH Accountable CareMedical Group, PLLC NY $17.15M $8.02M

Allcare Options, LLC FL $16.99M $6.06MQualuable Medical Professionals,LLC VA, TN $16.62M $7.41M

Accountable Care Coalition ofTexas, Inc. TX $16.04M $6.34M

What Employers Need to Do

• Expect Consolidation in Healthcare Market• Recognize that Primary Care Relationship is Key

to Health for Employees.• Push For Greater Transparency with Payers and

Conversations Directly with Providers.• “Own” Wellness and Target Benefit Design to

Reinforce Goals.• Align Incentives for Employees, Payer, and

Providers

33