making the numbers work...–acute care episodes (variation in medical decision making) –post...
TRANSCRIPT
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Making the Numbers WorkSession: PH3 March 5, 2018
Bruce K. Muma, MD, FACP
Matt Hussmann, MPH
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Muma, Bruce MD
Hussmann, Matt MPH
We have no real or apparent conflicts of interest to report.
Conflict of Interest
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Agenda
• Overview of Henry Ford Health System
• Taking the Plunge – Odds in Our Favor
• Strategic Approach – Hot Spots of Opportunity
• Data and Analytics – Building the Infrastructure
• Measuring Performance – Guiding the Journey
• Lessons Learned
• Critical Success Factors
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Learning Objectives
• Discuss details and critical success factors associated with transitioning to value-based care
• Identify business intelligence and financial analysis approaches that optimize organizational efficiency and effectiveness within various payment models
• Synthesize insights from successful business model strategies to ensure profitability and mitigate risk within population health management
• Translate the MACRA/Quality Payment Program into an actionable executive strategy for your organization
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• 8 hospitals, 200 care sites, DME, Home Care, Pharmacy, 30,000 employee’s serving > 1M lives in Michigan
• EPIC EMR with advanced EDW platform, 2017 Davies Award winner
• Comprehensive physician organization:
Henry Ford Medical Group: 1300 physicians & scientists, 26 medical centers
Henry Ford Physician Network: 2000+ employed and independent physicians
Henry Ford (Next Gen) ACO: 1400+ physicians on HF instance of EPIC
• Provider-owned health plan (HAP), 650,000 members
• Diversified, comprehensive retail services
• 3.2 million digital encounters, including MyChart portal, e-visits, and mobile telehealth visits
Henry Ford Health System Organizational Snapshot
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Taking the Plunge
• Early creation of ACO network – one of the first in Michigan (2010)
• Opted not to pursue Pioneer ACO opportunity (2012)
• Shared savings threshold
• Adverse impact of IME/DSH payments
• Retrospective attribution (HFHS EMR resources not yet fully implemented)
• Opted not to pursue MSSP opportunity (2014, 2015)
• Same reasons and savings threshold even worse
• Selected as one of 21 Next Generation ACO (NGACO) participants (2016)
• IME/DSH payment issue resolved
• Prospective attribution and 1st dollar shared savings
• Waivers helped remove care and cost management barriers
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Odds in our Favor?
• Large, academic health system serving as a safety net for an aging, underserved inner city population
• Regional referral center for several tertiary/quaternary centers of excellence
• Financial model and incentives aligned with volume based payment
• Local market not highly consolidated creating significant risk for “leakage”
• Potential to leverage learning/support from owned health plan (HAP)
• Potential to leverage EMR/EDW investment
– ACO providers required to be on our
instance of EPIC
– Simplifies data aggregation/reporting
• NGACO provides flexibility in financial model
– Upside/downside risk adjustable
between 80 – 100%
– Floor/Ceiling on losses adjustable
between 5 – 15%
• NGACO provides APM designation for
MACRA in early years
Perhaps Perhaps Not
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Next Generation
Target if Inefficient Target if Average EfficiencyTarget if Highly
EfficientHFHS Baseline (HFH estimated per capita costs - 2013) 12,145 12,145 12,145
HFHS Adjusted Baseline (Baseline with regional growth of 3.2%)2 12,534 12,534 12,534
HFHS Per Capita Growth at rate 389 389 389
Adjustments to Baseline:Target with Quality Discount (0 to1 %) -2.0% -2.0% -2.0%
Regional Efficiency (-1 to 1%) -1.0% 0.0% 1.0%
National Efficiency (-0.5 to 0.5%) -0.5% 0.0% 0.5%
Total discount -3.5% -2.0% -0.5%
Adjusted HFHS benchmark 12,095 12,283 12,471
Decrease Total Spend by 3%Total reduction from baseline (prior year) (7,300,000) (7,300,000) (7,300,000)
Medicare Scored "Savings" 6,300,000 10,000,000 13,800,000
Medicare Actual Savings (HFHS with 3.2% growth less 97% of HFHS Benchmark) 15,100,000 15,100,000 15,100,000
Shared savings 5,040,000 8,000,000 11,040,000 Increase Total Spend by 3% (Expected Growth Rate)
Total reduction from baseline (prior year) 7,300,000 7,300,000 7,300,000
Medicare Scored "Savings" (8,300,000) (4,500,000) (800,000)
Medicare Actual Savings (HFHS with 3.2% growth less 103% of HFHS Benchmark) 500,000 500,000 500,000
Shared savings (4,150,000) (2,250,000) (400,000)
Total Spend Maintained at Current Rate Total reduction from baseline (prior year) - - -
Medicare Scored "Savings" (1,000,000) 2,800,000 6,500,000
Medicare Actual Savings (HFHS with 3.2% growth less 103% of HFHS Benchmark) 7,800,000 7,800,000 7,800,000
Shared savings (800,000) 2,240,000 5,200,000
Sensitivity Analysis
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Strategic Approach• Use NGACO as a “tipping point” for HFHS Value Based journey – Socialize/Energize
– NGACO pushed HFHS (providers) beyond 33% of revenue in upside/downside risk
• Communicate/Advocate for Value Based Care:
– 40+ presentations to HFHS leadership bodies
– Synergize and integrate with allies (e.g., HAP, SNF Network, Care Management)
– Engage physicians (newsletters, articles, presentations)
• Engage beneficiaries
– Newsletters, phone hot line, EPIC MyChart enrollment
– Incorporate patient/caregiver convenience in design of new care models
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Strategic Approach
• Leverage the EMR/data/analytic platform (HELIOS)
– Clinical and claims data
– Risk prediction/benchmarking
– Performance dashboards
• Implement innovative care models to address the “hot spots” of waste
– Define framework, strategies, tactics
– Conduct ROI analysis
– Implement (as quickly as possible)
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Hot Spots of Opportunity
• Locate and define waste using available data and benchmarks.
– High/Rising Risk Populations (site of care)
– Acute Care Episodes (variation in medical decision making)
– Post Acute Care/Transitional Care (variation/outsourcing)
• Estimate impact of new care models/pathways (volume X unit cost)
– High Risk Populations – “top 5%” in prospective risk
– Acute Episodes – decision to admit, specialty referrals
– PAC – SNF LOS, readmissions
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2016 Actual Financial Performance - HFACO
Total Aligned Members: 20,330 (239,033 member months)
Total Benchmark Expenditures: $248,993,939.75 ($1,041.67 PMPM)
Total Performance Year Expenditures: $244,010,551.67 ($1,020.82 PMPM)
Total Savings after adjustments: $5,023,134.90 ($21.01 PMPM)
Shared Savings (80% of Total Savings): $4,018,507.92 ($16.81 PMPM)
Sequestration: ($80,370.16)
Net Shared Savings: $3,938,137.76 ($16.48 PMPM)
Achieved 2.0% savings from CMS benchmark target
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Value Based Care Programs
• Post Acute Care (PAC) Surveillance
• Emergency Department Disposition Support (EDS)
• Comprehensive Care Clinics (Ambulatory Intensive Care Units)
• Case Management integration
• Clinical Decision Support (Choosing Wisely/Referring Wisely)
• Non-domestic Hospitalist program
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Leveraging our IT Platform
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Key Enabler #1 – Patient Mastering
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Blend External & Internal Information
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Key Enabler #2 - External Claims• Able to see true performance of at-risk contracts
• Extensive initial effort rewarded
– Load Eligibility / Membership files first
– Determine a natural key for original, cancellation and adjustment of claims
• Only store the ‘final’ claim
– Normalize/map claims to other contract claims
• CMS and Commercial claims data structure look nothing alike!
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High Level Tracking of Populations
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Information at the point of care
Data is moved
upstream to
alert providers
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Dashboards & Scorecards for Programs
• Feedback loop to front line staff
• Program dashboards available to entire health system
• Staff scorecards available to program manager and employees
Own Your
Numbers!
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Future Directions
• Virtual Care Center for high risk populations
• System Integrated Palliative Care
• Radical convenience programs (EMR imbedded navigation, virtual care, outreach)
• Clinical Decision Support (broader EMR alert environment)
• Specialist variation in medical decision making
• Genomics for identification of most effective treatment
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Lessons Learned
• Perfect data not required – there is plenty of waste!
• Internal EDW analytic capability a required element in managing financial risk
• Build executive dashboard to allow tracking of performance for senior leaders
• Aggregation and analysis of claims/EMR data is hard - building trust with providers is harder
• Focus on the “large buckets” of waste and supporting providers to do the right thing (vs. imposing controls)
• Understand how to translate value based initiatives into traditional ROI models
– Revenue loss vs. capacity gain
– Adverse impact of volume based incentives
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Critical Success Factors
• Impossible to over-communicate the vision and expected challenges
• Engage clinical leaders as care processes owners and inspire them to create better models of care
• Multidisciplinary teams are vital for creating value across the horizontal continuum of care
• Build reliable metrics and dashboards to demonstrate value in population health programs in real time (as much as possible!)
• Engage finance team to fully understand and measure impact of value based care programs
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Questions
• Matt Hussmann: [email protected]
• Bruce Muma: [email protected]
• Please complete online session evaluation!!