RuthannRusso,PhD,MPH,LAc,ManagingDirector,BerkeleyResearchGroup

December8,2016

IntegrativePopulationHealth:Theintersectionofchronicconditiondocumentationandcodingwithdata-drivenreimbursement,patientsatisfaction,andcost

Whoherehaseverbeenapatient?

FourAssumptions:

Datadrivenpayment Chronicdiseaseprevalence

Payor-Provider-Employer-PublicHealthCollaboration EngagedConsumers:Health&Data

IntegrativeHealth

IntegrativePopulationHealth

Theuseofintegrativehealthpracticesto

• teachindividualsself-carestrategiestomanagechronicconditions;and

• increasethewellnessofpopulations

PrevalenceofChronicDisease:PercentageofHealthcareDollarsSpent

AcuteCare13%

ChronicCare87%

Source:CentersforDiseaseControl:http://www.cdc.gov/chronicdisease/

PrevalenceofChronicDisease:PercentageofHealthcareDollarsSpent

http://content.healthaffairs.org/content/30/11/2042/F1.expansion.html

Contributorstochronicdisease&prematuredeath

TheRootofAllChronicDisease:Stress+LifeStyle“Choices”Chronicstress– Raiseschatecholemines +suppressestheimmunesystem– Increasesreleaseofhistamines,complicatinglungdiseases– Increasescortisol,increasingbloodglucoseandtheriskofDM2– Causesinflammationinthecirculatorysystem– ActivatesthePNS,contributingtheANSdysfunction– Increasesepinephrine,heartrate,andbloodpressure

TheRootofAllChronicDisease:Stress

IntegrativeHealthModalitiesinclude…

• Practices thatpatientscanbetrainedtodoontheirownsuchasmeditation,yoga,andrelaxationresponse

• Therapies thatmustbeprovidedtoapatientbyalicensedpractitionersuchasacupunctureorbiofeedback.

10 10

Patientswhoengageinintegrativehealthpracticesare:

MorelikelytopracticeSelf-care

Moreactiveindecisionmakingwiththeirprovider

Morelikelytorequestandreadtheirhealth

information

Healthier

11

IntegrativeHealthPractice

TobaccoUse HBP Obesity Inactivity Anxiety Depression DM Pain

Meditation X X X X X X X

Imagery X X X X X X X

Biofeedback X X X X X X X

Yoga X X X X X X X X

Acupressure X X X X X X X

QiGong X X X X X X X

6EvidenceBasedIHInterventionsfor8CommonChronicConditions1

12

1From:Russo,Stitcher,&Diener.(2014).Thelowriskandhighreturnofintegrativehealthservices.JournalofHealthcareFinancialManagement.

Additionalinterventionopportunities:4StagesofPainModel

PainSensation/Intensity

PainUnpleasant

-ness

PainEmotion/Suffering

PainBehavior

Depression

Frustration

Anxiety/Stress

Fear

Anger

PainObservation

Response Responsibility

TellHurt

*ModelproposedbyMelzack &Casey(1968)andMelzack (1975)intheJournalofPain;Wade,Dougherty,Archer,&Price.(1996),Riley,Wade,Robinson,&Price.(2000).Wade&Hart(2002).

Additionalinterventionopportunities:4StagesofPainModel

Intervention Anxiety Depression Stress Response topain

Acupuncture X X X XBiofeedback X X X XPMR X X X XYoga X X X XHypnosis X X X X

Massage X X X XImagery X X X X

Meditation X X X XQiGong X X X X

Evidence-BasedIHInterventionsforStage3+4SymptomsofChronicPain

PopulationHealth

PopulationHealth– ParadigmShifting

16

PopulationHealth– ParadigmShifting

Insteadofwaitingforthepatienttocometotheprovider…...

PopulationHealth– ParadigmShifting

17

Basedondataandgaps,providersreachouttothepatient

• Treatthewhole population,notjustindividualsactivelyseekingcare

• Usedataandanalyticstomakeinformeddecisionsforhighutilizers

• Employbestavailableevidencetoguidetreatments

• Engageinactionablecaremanagementwithcondition-specificregistries.

1Sources:CMS,SAMSHA,CDC,AHRQ

PopulationHealth:Providers,Payors,orPublicHealth?

IntegrativePopulationHealth

IntegrativePopulationHealth:Defined

21

Evidence-BasedIntegrativeHealthTraining

Groups

HealthBehaviorChange:SupportedbyEHRandweb-basedtechnology

TOIMPROVE:• Chronicillnessmanagement• Healthpromotion• Self-care• Engagement

Fundedbymeasuredsavings

IntegrativePopulationHealth:Defined

ROIofIntegrativeHealth

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Results,atoneyearthefollowingdecreased:

• 43% Totalutilization• 41.9% Clinicalencounters• 50.3% Imaging• 43.5% Labencounters• 21.5% Procedures• 3.6/yr to1.7/yr EDvisits

MassachusettsGeneralHospital’sIntegrativeHealthGroups

SummaryofReducedCostsResultingfromIntegrativePopulationHealthInterventions

Decreased

• EDVisits• Inpatientcosts,

pharmaceuticals• Radiologyprocedurecosts• PostoperativeLOS• LabEncounters

Increased

• PatientSatisfaction• PatientEngagement• SymptomImprovement• Pain,depression,anxiety

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TheRootofAllChronicDisease:Stress+LifeStyle“Choices”• DoweevenhavevalidICD-10codesfor:– Theeffectsofstress?– Lifestylechoices?– Precursorstostress?

• Ifwedo,arecliniciansdocumenting&diagnosingpatientswithit?• Areprovidersprescribinganythingforthesepatients(besides

medications)?• Ifyes[suchastheSMARTProgram]arewecodingthis?Docodes

evenexistforsuchinterventions?• DowehaveANYreliabledataaroundSMART&Lifestyle

Managementprograms?

RelevancetotheHealthInformationProfessional

DataAnalytics:IntegrativeHealth+PopulationHealth

DataAnalytics:IntegrativeHealth

IdentifyCommonChronicConditions

SearchLiteratureandIdentifyEvidence-BasedInterventions

GroupInterventionbyType

AssignICD-10Codestoeachcondition,updatedannually

Assignevidencegradeandinclude1:Safe+GradesA&B(effective(A)orAppearstobeeffective(B)

1Evidencegradesobtainedfromoneormoreofthefollowing:AmericanCollegeofPhysicians,SocietyforIntegrativeOncology,AmericanCollegeofClinicalEndocrinologists,fromGuidelines.gov:FamilyPractice,Cardiology,PhysicalMedicine,Psychiatry,Kotsirilos (2011),Rakel (2012),Ernst(2010)..

Sources:Peer-ReviewedLiterature,CDCandCMS

P=Practicepatientsaretaughttodoontheirown

T=TherapybyqualifiedpractitionerS=SupplementD=Diet

IntegrativePopulationHealthCriteria:IntegrativeHealthAPP

IntegrativeHealthMed-ParAnalysis:PatientsWhoCouldBenefitfromIntegrativeHealthInterventions

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Hospital #Discharges %of cases

Hospital 1 3,554 98.1%Hospital 2 12,710 96.6%Hospital3 4,115 97.5%Hospital 4 9,715 97.3%

Hospital5 7,190 97.3%Hospital6 4,917 96.1%

Hospital 7 4,579 97.8%

Hospital8 2,938 97.8%

IntegrativeHealthMed-ParAnalysis:PatientsWhoCouldBenefitfromIntegrativeHealthInterventions

IntegrativeHealthMed-ParAnalysis:Differences:PatientswhocanbemanagedwithIHIvsthosewhocannot

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Hospital ALOSDifferential* Chargedifferential**

Hospital 1 1.82 29%Hospital 2 .24 4%Hospital3 .28 17%Hospital 4 1.25 20%Hospital5 2 26%Hospital6 .88 35%Hospital 7 1.86 32%Hospital8 1.24 18%

IntegrativeHealthMed-ParAnalysis:Differences:PatientswhocanbemanagedwithIHIvsthosewhocan’t

Diagnosis#of2013MD

Hospitalpatientswiththisdiagnosis

%ofIHMpatientswiththisdiagnosis

%ofallhospitalpatientswiththisdiagnosis

Highbloodpressure/hypertension

311,233 61% 53%

Diabetes,Type2 140,583 28% 24%Alcohol/DrugRelatedDiagnoses 131,773 26% 22%CoronaryArteryDisease 118,482 23% 20%GERD,Gastro-esophagealReflux 107,704 22% 18%Obesity/weightcontrol 104,895 21% 18%Depression 82,346 16% 14%Arthritis/osteoarthritis 73,230 14% 12%Pain 73,198 14% 12%Anxiety 67,758 13% 12%

TopdiagnosesinMarylandHospitals[All-Payer]thatCanbeManagedwithIntegrativeCare

SampleHealthcareSystemTop10Evidence-basedIntegrativeHealthPractices*

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IntegrativeHealthPractice Percentage**Yoga 95%Meditation 89%Biofeedback 88%Hypnosis 86%QiGong 86%Mediterranean/Anti-inflammatory Diet 81%RelaxationResponse 81%TaiQi 81%Imagery 72%CognitiveBehavioralTherapy 70%

**Percentofpatientsbenefitingfromintegrativehealthpracticeswhowouldbenefitfromthisparticularintervention

SampleHealthcareSystem:Top10Evidence-basedIntegrativeHealthPractices*

Topdiagnosesco-managedwithIntegrativeHealthAge18- 64

Topdiagnosesco-managedwithIntegrativeHealth

39

Hypertension

CAD

DiabetesT2

AtrialFibrillation

Arthritis

GERD

Depression

Anxiety

Age>64Hypertension

Alcohol/DrugDXs

DiabetesDT

Depression

Obesity

CAD

Anxiety

010

20

30

40

50

60

70

80

90

100

010

20

30

40

50

60

70

80

90

100

IntegrativePopulationHealthSnapshot:SampleHealthcareSystem[Med-Par]

Percentofpatientswhocanbeco-managedwithIntegrativeHealth

ALOSdifferentialbetweenpatientswhocanbemanagedwithintegrativehealthversusthosewhocannot

Avg totalchargedifferentialbetweenpatientswhocanbemanagedwithintegrativehealthversusthosewhocannot

IntegrativePopulationHealthSnapshot:SampleHealthcareSystem[Med-Par]]

40

96%

0

5

10

15

20

25

1 2 3 4 5 6 7 8 9

AllAges

18- 64

>64

Percentofpatientswith>5chronicconditionsthatcanbemanagedwithintegrativehealth

0

5

10

15

20

25

30

35

40

1 2 3 4 5 6 7 8

AllAges 18- 64 >64

0

0.5

1

1.5

2

2.5

1 2 3 4 5 6 7 8

AllAges 18- 64 >64

Amou

ntsa

rein

thou

sand

s

Days

86889092949698

100

1 2 3 4 5 6 7 8 9

AllAges

18- 64

>64

DataAnalytics:PopulationHealth

PopulationHealthAnalyticsTargetHighUtilizers:MultipleChronicConditions

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# of Chronic Conditions for Patient

Unique Patients

Total Cases

Total Charges

Average Charge per

Patient8 12 72 $696,816 $58,068 7 63 292 $2,159,642 $34,280 6 154 628 $4,517,694 $29,336 5 268 908 $6,888,829 $25,705 4 412 1,278 $7,660,776 $18,594 3 537 1,556 $7,718,457 $14,373 2 592 1,661 $6,635,607 $11,209 1 428 1,259 $4,379,734 $10,233

Chronic Total 2,466 7,654 $40,657,555 $16,487

Ofthe2,717HighUtilizers:§ 91%ofpatients(2,466)haveatleast1ChronicCondition

§ 91%ofcasesand96%ofchargesareassociatedwithpatientswithChronicConditions

§ 75%ofpatients(2,038)haveat§ > 2differentChronicConditions

PopulationHealthAnalyticsTargetHighUtilizers:MultipleChronicConditions

OverlapofPopulationHealth&IntegrativeHealth

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Highusersofpotentiallyavoidableservices

CanbenefitfromIntegrativeHealth

TargetPopulation

Althoughallpatientscanbenefit,beginheretooptimizereturnoninvestment

OverlapofPopulationHealth&IntegrativeHealth

RelevancetotheHealthInformationProfessional

PatientCommunication:EHR/Patient

Portal

ProgramRecommendations:OrganizationalGuidelines

DataAnalytics:Diagnostic&

ProcedureCodes

HIMprofessionalsdevelopstandarddocumentation&codingforIHtherapiesDiagnosisorChiefComplaint

Evidence-BasedSupportforTreatment

OfDiagnosisorSymptom

EHRStandardizedFormat

Development

DocumentationGuideline

Development

CodingGuideline

DevelopmentAcuteGIPain Acupuncture X X XAsthmasymptoms Yoga,breathingtechniques XCancerpain Acupuncture,massage X X XChemoTX inducedN&V Acupuncture,relaxationtraining X X X

Fibromyalgia Massagetherapy X X XInfertility Acupuncture X X XMajordepressivedisorder Aerobicexercise,yoga X X

Migraine Acupuncture,massage,meditation,MBSR,biofeedback,RR X X X

NeckPain Acupuncture X X XOsteoarthritisoftheknee Acupuncture X X X

CHD– Prevention Transcendentalmeditation,yoga XPost-operativepain Acupuncture X X XPregnancyinducedN&V Acupuncture X X X

Pre-operativeanxiety Guided imagery X X X

EngagingPatientsintheirHealthInformation

ConsumerengagementincareanddataEngagedpatients:• Becometheirownmanagers• Takeactiontomaintainandimprovetheirhealth• Participateinself-carepractices• Aremoresatisfiedwiththeircare• Onaverage,generatelesscoststothesystem

Consumerengagementincareanddata

EHROptimization:SamplePatientActionPlan

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Action Whatshould Idonext? Whyisthisimportant?Youaredueforyourcholesterolbloodtest

PleasegotoanyXYZsystemlabforablooddraw.YoudonotneedtofastUNLESSyourproviderinstructedyoutodoso.Youdonotneedanappointmentforthistest.

Acholesteroltestmeasuresthefatsinyourbloodandhelpsassessthehealthofyourheart,bloodvesselsandriskforheartattackorstroke.Itcanalsoshowifmedicationyouaretakingisworking

Youaredueforabloodpressurecheck

Gotoan XYZsystemprimarycaredepartmentforawalkinnocostbloodpressurecheck.Noappointmentneeded.

Monitoringyourbloodpressureisimportanttoyourhearthealth.

Youaredue foraTdap vaccine.

GotoyourXYZmedicalofficeandasfora“walk-in”immunization visitoryoucangetthisatyournextscheduledvisit.

TheTdap vaccineprotectsagainsttetanus,diptheria andwhoopingcough.

YouareinvitedtoparticipateinanintegrativeSkillsgroup

There isnocoststoattend.Call888-212-2222 toregisterforthehealthyskillsgroupnearestyou.Youcanalsoregisterforthegroupusingthislink.Clickheretofindoutmoreabouthealthyskillsgroupsandhowattendancecanbenefityou.

Learningand practicingthehealthyskillscanhelpyoumanagethesymptomsofyourhighbloodpressure.Itcanalsohelpyoumanagestress,chronicpain,anxiety,weightgain,anddepression.

EHROptimization:SamplePatientActionPlan

Patientswhoweregivenaccesstotheirnotes:

• 84%lookedatthenotes• 81%reportedtheyfeltmoreincontroloftheircare• 69%reportedincreasedmedicationadherence• 31%hadprivacyconcerns• 30%sharedtheirnoteswithothers• 99%continuedtoaccesstheirnotesafterthestudy

concluded

PatientEngagement&Satisfaction

• Wearethesourceofourhealthinformation

• Wewanttoshareourinformationto:– Experimentwithdifferentoptionsto– Improveourownhealth– Helpothers

• AND,atleastsomeofusarealsowillingtogiveupourrighttoprivacyinourhealthinformation

From:CureTogether.com

FromCureTogether.com

From:CureTogether.com

FromCureTogether.com

Relevancetothehealthinformationprofessional• Somepatientsaregivinguptheirrighttohealth

informationprivacyforthegreatergood

• Theincreasedimportanceofsymptomsingeneticresearch– Documenting– Coding

• Codingforhealthconsumer-generateddatathatismeaningfulanduseful

Relevancetothehealthinformationprofessional

FourAssumptions:

Datadrivenpayment Chronicdiseaseprevalence

Payor-Provider-Employer-PublicHealthCollaboration EngagedConsumers:Health&Data

Data-drivenPayment

ChronicDisease

PopulationHealth

ConsumerEngagement

Improve:documentation,codingIncrease:OPcare,documentation,coding

Increase:documentation,coding,datasourcesCreate:newcodes[SXs,stress,IH,groupTX]

Synthesize:datawithin&acrosssystemsQuantify:patient-generatedclinicalinfo

Design:patient-generatedEHRimprovementsManage:Personalizedgenomedata

Consumer-drivencare&consumer-drivendata:Theonly wayforward

Thankyou!RuthannRusso,PhD,MPH,LAc,ManagingDirector,BerkeleyResearchGroup

rrusso@thinkbrg.com