himss gc3_it takes a village (nov 4, 2016)
TRANSCRIPT
IttakesaVillage:BuildingaPopulationHealthManagementprogramthatworks
Friday‐ Nov4th,2016
Agenda
• What’s Driving the need for Population Health?
• Evolution of Population Health Programs
• Framework and Foundation
• Other Key Factors
• Results
• Summary
What’sDrivingtheNeedforPopulationHealth?
Challenges: Unprecedented Factors in Play
Increasing shortage of healthcare providers
Providers will adopt ‘Virtual Care’ to increase capacity
By 2030, 20% of Americans will be over the age of 65
100M patients trying to maintain or regain a healthy lifestyle
170M have at least one chronic disease
Patients in need of family & social support ‘Network’
Exponential growth in cost, with declining reimbursement
Patients will share the ‘Risk’ = Cost of care
Challenges:UnprecedentedFactorsinPlay
Consumersvs.Payers/Providers
Healthcare Attitudes 2016
WhatisPopulationHealthManagement?
Population Health Management is a systematic approach to optimizing the health of populations and preventing people from getting sick or sicker
Population Health Management uses data and technology to drive better health
outcomes for patients by giving providers the ability to monitor their entire patient population at-a-glance and in real-time
Opportunities:AMarketCravingforInnovation
Quality
Triple Aim
Moving from fee for service to fee‐for‐outcome
Streamlined care delivery across the continuum of care
Patient centric care with a focus towards well‐care vs. sick care
Technology:AKeyDriverinthisTransformation
Quality
• PPACA
• Meaningful Use
• Payer provider convergence
• Self‐monitored healthcare
• Physician engagement
• Virtual healthcare delivery
• HIE
• Clinical integration
• Electronic Medical / Health Records (EHR/EMR)
• Care financing
• Care management applications
• Physician management solutions
• Telehealth
• Practice management solutions
• Cloud
• Mobility
• Data analytics
• Cloud
• Big data analytics
• Mobility & Social media
• Internet of Things (IoT)
• Mobility & Social media
• Big data analytics
• Internet of Things (IoT)
Stakeholder Initiative Healthcare Tenet(s) Technology Tenet(s)
PopulationHealthManagementRedefined
Population Heath Management is a comprehensive set of activities focused on a defined population that improves quality and outcomes, while lowering per capita cost of care and is incentivized through contracts that accept financial risk and/or reward.
Value Quality + Patient Experience + Outcomes
Cost
EvolutionofPopulationHealthManagementProgram
PopulationHealthManagementProgramsareMaturing
• Transactional focus• Fragmented and siloed• Focused on discrete conditions and events
• Seen as restrictive and reactive
Traditional(Payer Based)
• Member centric• Condition based• Focus on trend mgmt.• Increased focus on:
‐Wellness‐ Gaps in care‐ Provider coordination
Advanced(Payer+ Based)
• Physician led‐ Accountable care models‐ Bundled payments‐ CPC+‐ DSRIP‐MACRA (MIPS & APM)
• Aligned incentives• Integrated at point of care• Value‐add services• Robust informatics
Aligned(Provider Based)
Alignm
ent a
nd Accou
ntab
ility
Engagement and Collaboration
PaymentModels:MovingfromPayerstoProvidersCareDeliveryModels:TradingVolumetoValue
Fee for service
Pay for coordination
Bundled payment
Pay for performance
Shared savings
Shared risk
Global capitation
Level of provider sophistication and collaboration
Degree of risk m
anaged
by provider
Comprehensive Revenue Cycle Clinical Integration
Financial Risk
ManagementPopulation Health Management
Value Based Reimbursement
Risk / Opportunity
StagedITInvestmentsbyProvidersunderRiskBasedContracting
Source: Health Care Advisory Board
FrameworkandFoundationofPopulationHealthManagement
SixKeyCapabilitiesneededtoSuccessfullyManagePopulationHealth‐ KLAS
The 6 core tenets, which KLAS calls “verticals”1. Aggregation of disparate clinical and administrative data to support
population health.2. Segmentation and analysis of aggregated data to communicate meaningful
information.3. Care coordination and health improvement tool to support standardized
intervention.4. Internal/external analysis of administrative and financial strategic
programs.5. Patient engagement aligned with goals for improvement.6. Actionable workflow integration to improve clinician engagement.
• http://www.healthdatamanagement.com/news/stakeholders‐identify‐key‐tools‐functionality‐for‐pop‐health?reading_list=%5B%2700000157‐bda4‐d031‐a57f‐fde4a66c0000%27%2C%2700000157‐ba5d‐d031‐a57f‐fbfd5b410000%27%2C%2700000157‐ba58‐d274‐a3df‐bad9e59b0000%27%2C%2700000157‐bdb0‐d274‐a3df‐bdf9b2a50000%27%2C%2700000157‐b890‐d274‐a3df‐b8d93fcc0000%27%2C%2700000157‐bdbd‐d031‐a57f‐fdfd65650000%27%2C%2700000157‐ba4f‐d031‐a57f‐fbeffa7d0000%27%5D
PopulationHealthManagementFramework
Technology Foundation
• Strategy
• Scope of Services
• Payer Relationship
• Quality Paradigm
• Community Alignment
• Financial Strategy
• Bundled Payment
• Risk Based Contracting
• Cost Accounting
• Financial Analytics
• Health Profiling
• Risk Stratification
• Care Planning
• Next Generation Care Delivery
• Outcome Management
• Outreach
• Education
• Care Coordination
• Collaboration
• Tracking & Monitoring
• Care Alignment
Business Model
Financial Model
EngagementModel
Care Delivery Model
Triple Aim
Better Care
PopulationHealthManagement‐MaturityMatrix
Phase 5TRANSFORMED
Phase 4OPTIMIZING
Phase 3ENHANCING
Phase 2FOUNDATIONAL
Phase 1CONCEPTUAL
Business Model
• Strategy in action• Cradle to grave services• Integrated self‐directed payer w/ >90% contracts at risk
• Quality measures adopted as standard
• Official dept. for community engagement
• Strategy funded• Affiliated network provides full suite of services
• >75% contracts at risk• Non‐regulatory quality standards adopted
• Individual responsible to include payers
• Strategy approved• External contracts provides suite of services
• >50% contracts at risk• Payer quality measures adopted• Individual responsible to exclude payers
• Strategy documented• Acute, specialty and primary care• Quality metrics tracked• Individual responsible for community members
• No Strategy• Basic acute care services• External quality measures for reporting purposes only
• Plan complies JCAHO
Financial Model
• ELT, finance & clinical alignment• CMS and commercial bundled pmt. contracts
• Full ACO strategy with risk sharing contracts managed
• Predictive reporting for cost accounting at patient level
• Reports driving costs out and improve quality
• ELT and clinical alignment• CMS bundled pmt. contracts only
• ACO strategy and risk sharing contracts in place
• Real time analytics for cost accounting at population
• Cost and care metrics
• ELT and finance alignment• Few bundled pmt. contracts• Risk sharing contracts but no ACO strategy
• Retroactive cost for population level
• Care metrics reporting only
• No cross disciplinary involvement
• No bundled pmt. • No risk sharing contracts• Departmental level costs• No analytic for cost/quality
• No financial strategy• No plan for bundled pmt.• No plan for risk sharing• Organizational level costs• No analytics capability
Care Delivery Model
• All health data including biometric and genetic
• Risk based on clinical, non‐clinical,claims, social etc.
• Evidence based longitudinal care plans for all patient type
• Mobile monitoring, wellness coaching and virtual care
• Culture of perf. improvement for pt. experience & outcomes
• Clinical, socio‐economic, environmental & daily activity
• Risk based on claims, clinical and non‐clinical data
• Low risk patients educated• Home monitoring and virtual visits for complex care
• Data transparency & coaching
• Clinical, socio‐economic and environmental data
• Risk levels based on claims• Rising risk patients proactively managed
• Telehealth use in acute care• Targets for care pathways
• Adds data collected via HRA• Risk levels based on HRA’s• Chronic disease mgmt. pathways• Limited telehealth use• Outcome & utilization tools
• Health data limited to EHR• Minimal risk stratification• Reactive and episodic• Not using telehealth• No outcome & utilization tools
Engagement Model
• Customized outreach based on customer preferences
• Personalized education when, and where needed by patient
• Pt. can access support services via digital channels
• Ongoing secure dialogue via several channels of comm.
• Collaborative goal setting w/ coaching to support progress
• Personalized staged outreach• Staged education with teach back and patient surveys
• Coordinates and tracks use of community support services
• Family & caregivers included• Tracked and monitored goals shared w/ broader care team
• Targeted outreach• Education accompanied by teach back method
• Coordinates support services• Regular comm. w/ care team• Trackable actionable goals
• Pt. managed outreach via email, portal, mail and phone
• Online info. accessible by pt.• Connects support services• Comm. via portal and phone• Actionable goals post visit
• Pt. outreach via mail & phone• Paper based education• Provides community resource• Episodic comm. via phone• Recommendation post visit
Technology Foundation
• Distinct PHM funding & resources
• PHM tech can automatically modify patient care plans
• IT governance has separate steering group for PHM
• Strategy and FHIR capabilities in place w/ integration from disparate sources
• PHM project dedicated resource
• PHM can provide utilization information for financial & clinical
• FHIR being investigated but no defined integration strategy
• PHM project contractedresource
• PHM technology partially implemented & future defined
• Robust IT governance but PHM not highlighted
• PHM projects fundedseparately
• Specific PHM tech. planned• Integration tools exist using
HL7, but no strategy in place
• PHM projects integrated w/ IT• No specific PHM technology• IT governance is not robust• Project based P2P integration
Phase 5TRANSFORMED
Phase 4OPTIMIZING
Phase 3ENHANCING
Phase 2FOUNDATIONAL
Phase 1CONCEPTUAL
TechnologyFoundationforPopulationHealthManagement
Monitor &
Measure
Care Delivery Layer
Engagement Layer
Data Integration Layer
Data Aggregation & Analytics Layer
8StepstoEnablePopulationHealthManagement
Design/refine the business and financial model
Identify and present care gaps as actionable insights via an easily interpreted dashboard
1Design/refine the business and financial model
Define 2Aggregate and normalize claims, clinical, HIE, registry and socio-economic data
Aggregate 3Stratify data to prioritize list of high risk and rising risk population
Stratify 4Identify and present care gaps as actionable insights via an easily interpreted dashboard
Identify
5
Create a personalized care plan for the
patients identified
Plan8
Measure and track against the expected clinical and
programmatic results
Measure 6
Engage with patients, families, communities and
clinicians to manage health conditions
Engage7
Coordinate with care teams for different
segments to improve outcomes
Manage
Improve Health | Lower Costs | Quality Care
CareStrategiesand/orInterventionProgramstoSupportDistinctPatientPopulations
PrioritizeInvestmentsbyPatientPopulation
1). Investments may be for partnerships, rather than acquisition or brick-and-mortar2). Investments here may be for retraining existing staff, rather than hiring new staff.
Source: Health Care Advisory Board Interviews & Analysis
CareManagement:ServicesacrosstheEntireLifecycleofPatient’sHealthcareDeliveryNeeds
Care Management
Care Intervention
Diagnostics Treatment
Wellness Management
Medical Adherence
Management
Monitoring & Tracking
Patient Profiling
Comprises a collection of people, processes and technology to improve population health collaboratively
Comprises of post-intervention activities to maintain health
Comprises of onsite or remote care delivery based on analysis for right diagnostics and medical treatment
Applications that diagnose illness or help with early detection by analyzing lab results and patient records
Applications that identify right treatment (drug, provider or cost) methods based on big data analysis
Applications that track medicine intake after onsite or remote care intervention
Applications that track body’s real-time vitals through IoT applications
Applications that profile patients based on food habits, exercise regime and medication to send customized alerts via mobile devices
Source: Everest Group
LinearViewofCareManagementApplications
Tele-psychiatry
Medication mgmt.
Tele-stroke
Chronic care mgmt.
Virtual urgent care
Retail care
Wearables
Mobile appsVirtual primary care
Patient portals
Online support groups
Clinician
to
Clinician
Provider
to
Patient
Consumer
Driven
Tele-dermatology
2nd opinion
School health
Prescription refill
Wellness, disease mgmt.
Tele pharmacyTele-radiology
Tele-cardiology
eNICU
Tele-retinal image
Tele-pathologyTele-audiology
eICU
2nd opinion
Tele-surgeryTele-trauma
eVisits
Geo-tagged devices
Telehealth:BusinessModelsEvolvingtoLiveCustomerInteractiveSystem
Source: Everest Group
ChecklistforPHMPartnerships1. Commit early on to develop the competencies and infrastructure required to advance
population health.2. Acknowledge that owning or operating every component of the care continuum is
probably not possible for most organizations. Partnerships will be a valuable asset, especially those with post‐acute offerings.
3. Have clear goals for partnership arrangements and specify how success will be defined and measured.
4. Define the partnership network delivery elements and responsibilities.5. Determine which party is responsible for functions such as population health analytics
and utilization management.6. Consider arrangements that will allow your organization to manage population health
without assuming full financial risk for an insurance product.7. Evaluate various product offerings that are available through partnerships with insurers.8. Determine the level of provider risk your organization desires to carry.9. Identify the means of economic integration the partnership will offer, as well as the
expected revenue model.10. Identify the assets your organization will contribute to or invest in the partnership.11. Determine the terms for ending the partnership.
Source: Kauffman Hall
ComparingVendorPartnerstoYourNeeds
Score
Priority
Score
Priority
Data security Custom reportingData silos Standard reportsData acquisition timing Custom stabilityData reporting timing Client list / ExperienceData exportable Base costData normalization Care coordination programBig data platform Alerts / RemindersScalability Best practices ‐ Value drivenIntegration to HIE / platform Risk assessmentProven connectivity Provider attributionAPI‐Driven Interface Patient registration / identificationCloud multi‐tenant Total cost of care
OtherKeyFactors
MostFactorsthatImpactHealthareNotClinical
ConnectandCoordinateCareAcrossthe"PatientContinuum”
PopulationClinically Integrated Network
Source: Jonathan Weiner, Center of Population Health IT Johns Hopkins Bloomberg School of Public Health
Provider‐PayerCollaborationisKey
Provider‐payer relationships are evolving in the era of payment reform and value‐based care. The “us vs. them” mindset needs to evolve into a collaboration built on trust and respect. Payers and providers must continue to successfully align their goals in order for both to succeed and patients to benefit
Principles of Sustainability
1. Attribution – linking people to their PCP
2. Define episodes – whole person vs. disease
3. Transparency – data and variation
4. Metrics that matter
5. Aligned incentives
CapabilityMaturitybetweenProviderandPayerforPopulationHealth
Results
TypicalPopulationHealthCareDeliveryChallenges
Limited Risk Analytic Capability
Dated Technology
No Cost or Care Metrics
Disengaged Family & Caregivers
Limited Population Insights
Inability to Contract Risk
Lack of Strategy
Misaligned Network & Leadership
BytheNumbersMedicare Advantage spending exceeds
$175B$225B
of Medicare FFS spending moving into ACO’s and Bundled
Payments
$160BMedicaid spending shifting gradually to
Value‐Based Payments
$580Bof employer spending through private health
plans
SuccessisNotEasy:MSSPPerformance
Summary
CharacteristicsforaSuccessfulValueBasedOrganization
Engage physician
leadership and
dismantle silos to
better coordinate
care, align
resources around a
shared goal of
high‐quality care
Maximize operational
efficiency, expansion
potential and
economies of scale
Balance care quality,
efficiency,
accessibility and
benchmarks for local
market
Manage and utilize
relevant data to
make key clinical and
organizational
decisions
Establish policy and
procedures for
physician education
and remediation to
harness change and
drive the
organization forward
Governed
TheIdealSolution!
Comprehensive
Not just population
health analytics
Modular
Not just rip and replace
Predicting Future Risks
Not just reporting past claims
Continuum of Care
Not just visit based
Strategic. Outcome
based. BPaaS Solution
DESIGN BUILD OPERATE
