long life with quality: a value based proposition for pcps ... · long life with quality: a value...

Long Life with Quality:

A Value Based Proposition for PCPs

Susan J. Beane, MD

December 2, 2017

©2016 HF Management Services, LLC. 12/5/2017 1

The Context

• Transforming Our Delivery Systems

The Evidence

• The Case for Longevity

The Opportunity •Change of Focus: Longevity by

Mitigating Risk and Promoting Health s a Value Based PCP Strategy

Call to Action

Agenda

Healthfirst at a glance

• Founded in 1993 by a number of voluntary and public hospitals in the New York metropolitan area

• A not-for-profit health insurance company that offers low- or no-cost programs to residents in our New York service area

• We have 1.25 million members*

• 1 in 8 New York City residents is a Healthfirst member#

• $8.6 billion in annual revenue

• Ranked as the 4th largest health insurance company in NYC by Crain’s New York Business^

* Combined NYC, and Long Island, and Westchester county

# Data from the US Census Bureau, July 2016 annual estimate. Member data as reported by NYSDOH, QHP/EP 2016 Enrollment, and CMS

^ 2016 Crain’s New York Business healthcare industry list of the 10 largest health insurers in New York City, ranked by the number of enrolled

members in NYC

©2017 HF Management Services, LLC.

The information contained herein is CONFIDENTIAL AND PROPRIETARY. Do not disseminate, distribute or copy.

•

Staten Island PPS- Age groups and Member Zip codes

Age Groups 18-30 30-39 40-49 50-64 65+

-

500

1,000

1,500

2,000

2,500

3,000

3,500

18-30 31.8%

30-39 22.8%

40-49 16.5%

50-64 25.1%

65+ 3.8%

Age Groups

-

200

400

600

800

1,000

1,200

1,400

1,600

1,800

10304 17.4%

10314 15.5%

10301 11.9%

10305 11.8%

10306 10.4%

10303 9.2%

Zip Codes

Service date: Jan- Oct 2017

Report date: November 2017

Created by: Clinical Analysis and Informatics

When care goes wrong: Dilemma of Emergency Admissions

12/5/2017 ©2016 HF Management Services, LLC. 5

Emergent Admissions - 50% to the hospital affiliated with their PCP

- 60 people accounted for the 30 day readmissions

• If the member was admitted to a facility aligned with their PCP, the readmission rate was 18.8%

- If the member was NOT admitted to their PCP’s admitting hospital, the readmission rate was 32%

• 35% of members were admitted OUTSIDE OF STATEN ISLAND

• 34 members were admitted >=2 times in 30 days

- 73 members were admitted >=3 times in 180 days

In 3Q17 320 unique members were admitted with 30 day readmit rate of 25%

Trajectory of Health for HF members in Staten Island: Longevity and Equity


Potential Future Impacts

Provider & Delivery System: How can we discover and enhance member outcomes to improve quality. utilization and avoidable ED and Inpatient visits

Members: address social AND clinical factors

Clinical outcomes Engagement in care

Why equity matters:

• Population Stratification

• Framework for quality improvement

• Future Impacts

• Short Term

• Can we reach our least engaged members?

• Mid Term

• Can we rally our providers around Longevity and Equity?

• Long Term

• Can we improve performance at the MCO level?

The impacts of inequities are not easy to gauge for managed care organizations, but the evidence for identifying high risk populations is mounting.


Goals of Advanced Primary Care

Healthier people

Better manage

population health

Smarter spending

Better Care


•

Healthfirst Managed Care Model: Value over volume is built into the “DNA”

•Critical success factors • Implementation of evidence based medicine • Collaboration across the delivery system and with public

health initiatives • Practice based care-coordination to manage quality and

cost of care • “Nimble”- able to adapt to changing disease burden of

patients and evolving systems of care

• Major challenges:

• Volume and engagement of membership

• Performance in Quality Program

• Strategic Approach to building YOUR value based model

Achieving optimal outcomes in a Value

Based Healthcare World


•

Mismatch between our perspective . . .

Patients, Tests,

Rx’s, Emergency

Room, Chronic

Illness, Cases,

Practice staff

. . . And our patients


•

a. Listen to me

b. Coordinated Care

c. Take time to understand my goals and concerns

d. Tell me the risks of each rx option

Based on a national survey of adults, what was the most

frequent answer to the following question: “I want my

provider to . . .”


•

The Gap

Alston, C., L. Paget, G. C. Halvorson, B. Novelli, J. Guest, P. McCabe, K. Hoffman, C. Koepke, M. Simon, S. Sutton, S. Okun, P.

Wicks, T. Undem, V. Rohrbach, and I. Von Kohorn. 2012. Communicating with patients on health care evidence. Discussion Paper,

Institute of Medicine, Washington, DC. http://nam.edu/wp-content/uploads/2015/06/evidence.

• Only 47% of

patients stated that

their provider takes

into account their

goals and concerns

• Only 36% strongly

agreed that their

provider explains

the latest medical

evidence

• Only 37% said that

their provider

explains the option

of not pursuing a

test or treatment


•

Non-Transformed, non Value State

Lynn J, Straube BM, Bell KM, Jencks SF, Kambic RT. Milbank Q. 2007 Jun;85(2):185-208; discussion 209-12.

Provider Focused Health System

Patient adjusts

Providers’ Time

Practice Patterns

• Healthcare delivery system-centric

•Problem List

•SOAP Note

• Characterized by fragmented,

discontinuous, often dehumanizing

patient experience

• Can promote wasteful, and

unreliable care

• Every practice, every provider,

every patient is an island

Patient as disruptive force to practice:

Birth of the “Non-Compliant patient”

Disorder-centric PCP approach


•

Primary Care Patient Mix: Driven by the “Chief Complaint”

Addressing the Leading Causes of Years Lost to Disability and Death • Alcohol Use Disorders • Cirrhosis • CKD • Diabetes • Drug use disorders • Falls • Low Back Pain / Musculoskeletal disorders / Neck Pain / Osteoarthritis • Major Depressive Disorder • Schizophrenia

Institute for Health Metrics and Evaluation. (2013). The State of US Health: Innovations, Insights, and Recommendations from

the Global Burden of Disease Study. Seattle, WA: IHME.

Impacting Longevity and Health Outcomes:

A Current “Hot Topic”


What your patients are reading . . . HOW

NOT TO

DIE


•

Patient Goal: Long life with Quality

A person’s health trajectory

starts with genetics and

traverse where living, playing,

and working occur.

Aging itself … without

intervention curtails longevity,

self-sufficiency and health

World Health Organization - Noncommunicable Diseases (NCD) Country Profiles, 2014. http://www.who.int/nmh/countries/usa_en.pdf?ua=1. Accessed August 5, 2016.

The Challenge of Premature Mortality

http://www.who.int/nmh/countries/usa_en.pdf?ua=1

• Maximum life span is “known” (NEJM 1980)

• (110-114 years)

• 85 years is projected ideal average life span

• Most life span gains made in childhood

• 80% of non traumatic premature death due to chronic illness after age 60

• Postponing chronic illness can raise the age of first infirmity and impact the markers of aging, can extend “adult vigor”, compress disabling morbidity to “end of life” and decrease mortality

Main Finding: Preventing and delaying atherosclerosis should be the goal

The Ideal Average Life Span

Fries JF. Aging, natural death, and the compression of morbidity. N Engl J Med. 1980;303(3):130–5.

• Models the impact of treatment v risk factor reduction to account for improved ischemic heart disease mortality rates between 1992 – 2009

• Majority of impact is treatment based rather than risk factor based

• 12% or reduced deaths were due to primary prevention and secondary prevention after a heart attack.

• This reduction would be considered an addition to DALYs

Chernow, M., Cutler, D. M., Ghosh, K., & Landrum, M. (2016, June). Understanding the Improvement in Disability Free Life Expectancy In the U.S. Elderly Population. NBER Working Paper No. 22306.

How is decline in IHD mortality achieved?

Effect of Modification of Individual Risk Factors

Chernow, M., Cutler, D. M., Ghosh, K., & Landrum, M. (2016, June). Understanding the Improvement in Disability Free Life Expectancy In the U.S. Elderly Population. NBER Working Paper No. 22306.


•

Aligning with the Patient’s Goals … engagement … shared decision making

• Based on IOM Crossing the Quality Chasm (2001)

• Using Information-rich environment

• Patient / advocate engagement in all aspects of care

• Coordination among teams of caregivers toward common goals for citizens and people

Segmented patient

Population

Right amount of practice

time

Right practice Resources

Targeted to Desired

effectiveness and efficiency

1. Define optimal health for each patient population

2. Stratify each person into their population

3. Prioritize and focus on agreed upon health needs and outcomes


•

Using Population Segmentation to Provide Better Health Care For All

Lynn J, Straube BM, Bell KM, Jencks SF, Kambic RT. Milbank Q. 2007 Jun;85(2):185-208; discussion 209-12.

Your Patient’s Personal Goal

Staying Healthy

Practice Patient Population

Healthy Maternity/

Infant Health

Getting Well

Practice Patent Population

Acutely Ill

Living with illness or disability


Chronic, normal

function, stable

trajectory

Significant but

relatively stable

disability

Coping with illness at End of life


Dying” – short

decline

Limited reserve; Serious

Exacerbations

Long course of decline from

dementia or frailty

EFFICIENT FOR PRACTICE AND

PROVIDERS!

Can structure the supports, service arrays,

and care delivery so to meet the needs of

anyone in that segment reasonably well.

In the “Bridges to Health” Model

each person needs somewhat different

services for optimal health based on their

population segment.

Highest value Cluster of opportunity

• Risk Factors: hypertension and smoking

• Diseases: IHD and Stroke

Institute for Health Metrics and Evaluation. (2013). The State of US Health: Innovations, Insights, and Recommendations from the Global Burden of Disease Study. Seattle, WA: IHME.

What if we ask about leading risk factors?

Moderate impact “risk

factor mitigation cluster”

• 6-10% of premature

deaths

• 5% of DALYSs

Each risk factor impacts multiple disorders in a meaningful way

Risk Factor Reduction and DALYs

• Overall opportunity to impact multiple conditions with specific recommendations by condition

• Example: A patient can use Dietary risk factor reduction to impact 15% of total DALYs

• Cancer

• CVD

• Diabetes

• Proposes critical and sensitive periods across the life course impacted by external factors that may be:

• Cumulative – additive, multiplicative as well as protective over time

• Period-specific – factors influencing specific time periods

• Certain factors are more dominant influencers depending on age

Trajectory of health set in childhood

Halfon, N., Inkelas, M., & Hochstein, M. (2000). Halfon N, Inkelas The Health Development Organization: An Organizational Approach to Achieving Child Health Development. The Milbank Quarterly, 78(3), 447-497.

Berenson GS et al. N Engl J Med 1998;338:1650-1656.

The Influence of Cigarette Smoking on the Prevalence (Top Panels) and Extent (Bottom Panels) of Atherosclerosis in the Aorta and Coronary Arteries in Children and Young Adults.

“Even though the lifetime amount of smoking may be relatively low at young ages,

its adverse effects are obvious.”

Even with relatively short duration of smoking

higher prevalence of atherosclerosis

CVD Risk Factors in Recently Diagnosed Youth with Type 2 DM

Even with relatively short duration of type 2 DM (average 1.5 years) higher % of multiple CVD risk factors

• Cause and effect with obesity

• Hyperglycemia possibly independent contributor to risk

West, Nancy A. et al. “Cardiovascular Risk Factors Among Youth With and Without Type 2 Diabetes: Differences and Possible Mechanisms .” Diabetes Care 32.1 (2009): 175–180. PMC. Web. 10 Aug. 2016.

5 distinct BP trajectories identified:

• Absolute and statistically significant increase in likelihood of a CAC score >=100 HU for moderate – elevated groups compared with low stable group

• For highest risk group, associated with, but independent of, CV Risk Factors

Connecting the dots . . . BP trajectory from young adulthood through middle age

Allen, N. B., Siddique, J., Wilkins, J. T., Shay, C., Lewis, C. E., Goff, D. C., et al. (2014). Blood Pressure Trajectories in Early Adulthood and Subclinical Atherosclerosis in Middle Age. JAMA, 311(5), 490-497

CARDIA Study collected BP readings prospectively for 4681 participants aged 18-30 at baseline and then

multiple readings between years 2 and 25.

Outcome: Coronary artery calcification (CAC) at year 25 as indicator of subclinical atherosclerosis

100 HU= high risk of coronary event of coronary event.

“ … these findings

suggest that an

individual's long-

term patterns of

change in BP

starting in early

adulthood may

provide

additional

information

about his or her

risk of

development of

coronary

calcium.

120/80 MAP=93

Trends of Type 1 and Type 2 Diabetes among Youths, 2002–2012


• P values are for the linear trend tests in each racial or ethnic group, according to type of diabetes.

• Significant results suggest a positive annual rate of increase during the study period.

Mayer-Davis EJ, Lawrence JM, Dabelea D, et al. Incidence trends of type 1 and type 2 diabetes among youths, 2002–2012. N Engl

J Med 2017;376:1419-29. DOI: 10.1056/NEJMoa1610187

Model-adjusted incidence estimates per 100,000 youths.

Asian, African American, Hispanic, and white children exhibit different degrees of synergism between blood pressure and BMI


However, obese white adolescents had the highest prevalence of sustained hypertension (7.4%) compared with obese African American adolescents (4.5%, P < .001)

School based screening of 21 062 adolescents aged 10 to 19 years (mean, 13.8 years) Houston Pediatric and Adolescent Hypertension Program at U of T

Race and Obesity in Adolescent Hypertension Eric L. Cheung, Cynthia S. Bell, Joyce P. Samuel, Tim Poffenbarger, Karen

McNiece Redwine, Joshua A. Samuels,Pediatrics Apr 2017, e20161433; DOI: 10.1542/peds.2016-1433

At lower BMI percentiles (<60th percentile), Hispanic adolescents actually had the lowest predicted prevalence of hypertension among the 4 groups.

The final prevalence of sustained hypertension (elevated for 2- 3 screenings within 2 months) in all subjects was 2.7%

The highest rate of hypertension was seen in Hispanic (3.1%), followed by African American (2.7%), white (2.6%), and Asian (1.7%) adolescents

Obesity rates were highest among African American (3.1%) and Hispanic (2.7%) adolescents.

• Follows individual level health trajectory and economic outcomes

• Separates out relationships among disease, disability and spending • Can mimic age related chronic diseases and disability simultaneously

Modeling the Future: Innovations for better health and longer life

Goldman, Dana P., David M. Cutler, et al. Modeling the Health and Medical Care Spending of the Future Elderly. Santa Monica, CA: RAND Corporation, 2008. http://www.rand.org/pubs/research_briefs/RB9324.html.

DALY = Disability-free years of life = The sum of years lost due to

premature death (YLLs) and years lived with disability (YLDs)

Chronic diseases commonly cared for in primary care practices have a negative impact on longevity for Medicare beneficiaries.

Prevention innovations would improve DALY and cost outcomes for Medicare beneficiaries with hypertension, tobacco use, obesity and diabetes.

12/5/2017 33

How to make “Longevity” = Value

S. Kogan, http://dtpdoctors.com/. Accessed 11/3017

http://dtpdoctors.com/

http://dtpdoctors.com/

• Well-being • Health and Function

• “Wealth”

• Disease and Health Care Services

• Environmental “Stressors” • Social

• Physical

• Genetic

Consider futuristic approach to “CC” and “ROS” (WHODAS 2, for example)


CONVERSATIONS!

Empower the Voice of Your Patients

What brings you to my office

today?

“I want a long, healthy life

for me and my family.”

“Can I reverse my diabetes/

high cholesterol?”

“ I can’t do anything that I

used to do.”

“Stress is killing me.”

“ I just don’t feel right.”


•

Avoid Fatalism . . .

Primary Care Practices CAN align evidence based medicine with

patients’ goals and challenges to achieve improved outcomes.

Have an aim:

To move patient to a trajectory optimized for long term health

Endorse a Strategy

• Compress morbidity and support reaching and surpassing genetic potential

• Holistic approach that encompasses home, workplace, family / social isolation


Be Strategic … for your population of patients Risk Reduction and Prevention

Commit to Measurement . . .

Here with her daughter – who comes to translate for her mom. In her 50’s and healthy.

As measured by quality

and future risk

AIM: To move patient to a trajectory optimized for long term health

STRATEGY:

• Mitigation Plan to address the CUMULATIVE impact of risk factors

• Promote Health

• Identify cumulative risks

• Introduce Protective Factors

CARE PLANNING:

• Patient Goals identified and addressed in Shared Decision Making framework

• Use Motivation to address factors in manner that makes sense for patient to achieve your agreed upon desired outcomes

“I want a long, healthy life for me and my family.”

My cholesterol is high. WHAT!!! It was always low before. I’m only in my 30s.

Sheldon - In my 30s with a new baby. I want to be around with my wife to see our grandkids!

Summary: Transforming primary care

Healthier people in Staten Island

Better manage population health

Smarter spending

Better Care Data and Measurement

are your friends! (PPS)

Strategic Approach to YOUR populations and neighborhoods (PPS)

Avoid Fatalism • Conversations with your

patients • REALLY HEAR THEM • Connect Dots for them

using trusted partners (PPS)

Using an Evidence Based approach to Longevity and Quality of Life checks all of the boxes for Value!

Susan J Beane, MD

VP, Medical Director for Clinical Partnerships

Healthfirst

100 Church Street | New York, NY 10007

Office: 212.823.2437 Mobile: 646.419.0059

Visit us online at healthfirst.org| HFHealthyLiving.org

Contact information

©2017 HF Management Services, LLC.

https://healthfirst.org/

http://hfhealthyliving.org/

long life with quality: a value based proposition for pcps ... · long life with quality: a value...

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