ohio aug 2012 (cmprssd)

PopulationHealth

System Integrator

PatientExperience

The System Integrator

Creates a partnership across the medical

neighborhood

Drives PCMH primary care redesign

Offers a utility for population health and financial management

Per Capita Cost

Productivity

The Quadruple AimReadiness, Experience of Care, Population Health, Cost

28 Copyright 2011 by IBM

How Ohio BEAT the HEAT Zero Death !!!

How Ohio BEAT the HEAT Zero Death !!!

2010 2011ER visits -6.6% -9.9%Primary care sensitive ER Visits -7.0% -11.4%Ambulatory care sensitive Hospitalizations (per 1,000) -11.1% -22.0%

State Michigan working with BCBS Dow, IBM, Autos $ 7.5 PMPM investment $18 PMPM return

Copyright 2011 by IBM12

PCMH North Dakota Congratulations FIRST with all DOCs PCMH!! a hospitalization rate 18 to 24 percent below average hospital stays 38 percent shorter an amputation rate among diabetics 60 percent

lower than average Increased in value-based, targeted pharmaceutical

agents in support of chronic disease evidence-based standards.

most remarkable of all, these improved outcomes have come with a decrease total cost.

In ND Would Zsa zsa still have a leg to stand on your MOM??


36.3% Drop in hospital days32.2% Drop in ER use 12.8% Increase Chronic Medication use -9.6% Total cost 10.5% Inpatient specialty care costs down18.9% Ancillary costs down 15.0% Outpatient specialty downOutcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence from Prospective Evaluation Studies in the US K. Grumbach & P. Grundy, November 16th 2010

Smarter Healthcare


Copyright 2011 by IBM

Actual client data: Midwest Hospital with 12,135 employees 1 year self-funded for group health

$569

$805

17

$804

$765

Per Employee Per Month Health Costs

Post Implementation

Hospital build own Employee PCMH State JoinsHospital build own Employee PCMH State Joins

Why Innovate? Affordability

Costs continue their upward climb with employers paying much of the tab

Source: Dr. Martin Sepulveda Source: Dr. Martin Sepulveda Copyright 2011 by IBM

- Employer Cost - Employee Payroll Contributions - Employee Out of Pocket Expenses

5

The elephant in the room

2001 2009 2019

118%

166%

The Cause? Mostly due to fee-for-service payments and an over reliance on rescue/specialty care. This is stark evidence that the U.S. health care Industry has been failing us for years “Commonly cited causes for the

nation's poor performance are not to blame - it is the failure of the delivery system!!”

- Unaccountable Care Organizations!!! *Source: Peter A. Muennig and Sherry A. Glied Health Affairs Oct. 7, 2010

Dubuque, Iowa Genesse, MI

Ogden, UTFargo, ND

Dubuque, Iowa Genesse, MI

Ogden, UTFargo, ND

USA 2011USA 2011


Least Expensive Most Expensive Ogden, UT $2,623 Dubuque, IA $2,719 Genesee, Mi $2,957

Anderson, IN $7,231

Punta Gorda, FL $7,168

Racine, WI $6,528

Cost of Commercial lives


WellPoint's New Hire - What Is Watson?


OHIO

PCMH Practice redesign - Promotion and widespread adoption of the patient-centered medical home practice model

Ohio Primary Care Workforce Collaborative (198) Benefit redesign to value based –Ohio as employer.

Payment reform – CPR value vs volume Engaged Business and Industry Leaders

PreventiveMedicine

Behavioral Health

MedicalAssistants

MedicationRefills Acute

Care

NursingCase

Manager

Test Results

HealthcareSupport

Team

ChronicDisease

Monitoring

DOCTOR

Practice Transformation Episode of Care Over

Source: Southcentral Foundation, Anchorage AK

Medical information is doubling every 5 years, much of which is unstructured

81% of physicians report spending 5 hours or less per month reading medical journals

Healthcare Industry is beset with some of the most complex information challenges we collectively face –In fact the current structure has failed us.

Source: International Journal of Circumpolar Health, DoctorDirectory.com, Institute for Medicine"

Payment reform requires more than one method, you have dials, adjust them!!!

“Pay for health”

“Pay for outcome”

“Pay for Management “Pay for Coordination

“fee for good service”

“Pay for satisfaction”

“Pay for health”

“Pay for outcome”

“Pay for Management “Pay for Coordination

“fee for good service”

“Pay for satisfaction”


17

% Total Healthcare

Spend

% of Members

Benefit Redesign - Patient Engagement Different Strategies for Different Healthcare Spend Segments

Those who are well or think they are well

Those with chronic illness

Those with severe, acute illness or injuries

17

FEHB Program Carrier Letter All Carriers U.S. Office of Personnel Management-Federal Employee Insurance Operations -Letter No. 2012-09

We are reinforcing our support for patient centered medical homes (PCMH). We are again calling for to increase FEHBP members’ access to primary care providers who have adopted the principles of the medical home..

29 March 2012 29 March 2012

OPM and PCMH level care

OPM Technical guidance 19 April 2012 requires all Plans to Submit:

Criteria for PCMH recognition Percent and listing of all plans that have reached certification Number of covered lives in PCMH Recommended Provider payment incentives Plan to invite Patient into PCMH level care Quality outcomes associated with PCMH Inclusion in all CMS and state PCMH initiatives efforts (like

CPCi , MAPC).

OPM $39 Billion Book with Accountable CarePatient at the Center

24-7 clinician phone response Provide open scheduling. Provide care management and

coordination by specially-trained team members.

Use an EHR with decision support.

Use CPOE for all orders, test tracking, and follow-up.

Medication reconciliation for every visit.

Prescription drug decision support.

Implement e-prescribing. Registry

Pre-visit planning and after-visit follow-up for care management.

Offer patient self-management support.

Provide a visit summary to the patient following each visit.

Maintain a summary-of-care record for patient transitions.

Email consultations. Telephone consultations. The development of care

plans. Performance outcome measures.


Multi-state and National exchange

- Section 1334

OPM base of the multi-state exchange and the national exchange -- everyone is so focused on the states they miss the fact that OPM under the law is the agent for the other two exchanges it is built on this carrier letter.

OPM requirements are found in Section 1334 of the ACA for OPM to contract with health insurers to offer multi-state qualified health plans ("MSQHPs") to the individual and small-group markets.

The contours of OPM's implementation of the MSQHP contracts will have a significant impact on health insurance issuers that will participate in the state-based "American Health Benefit Exchanges" ("Exchanges") for the individual and small-group markets.

CPCI Five Functions/Framework For Comprehensive Primary Care

Risk stratified care management Access and continuity (24/7 with EMR) Planned care for chronic conditions and

preventive care (proactive management) Patient and caregiver engagement Coordination of care across the medical

neighborhood

22

COLORADO 18% decrease in acute IP admissions/1000, compared to 18% increase in control group

15% decrease in total ER visits/1000, compared to 4% increase in control group

Specialty visits/1000 remained around flat compared to 10% increase in control group

Overall Return on Investment estimates ranged between 2.5:1 and 4.5:1

PCMH Preliminary Year 2 Highlights

NEW HAMPSHIRENEW HAMPSHIRE

New York

Large company RFP -Patient Centered Medical Home

Are you doing anything to build community support for members by collaborating with Primary care physicians in initiatives such as patient centered medical homes. If so, please describe and note how this could impact or company.

If not building patient centered medical homes actively you will not be considered for 2012.

Forbes- "Primary Care Spring" unleashed by IBM. Forbes- "Primary Care Spring" unleashed by IBM.

BUYINGVALUE July 18 2012 Employers Buy Health Care That’s Proven to Work

PRIVATE PURCHASERS OF HEALTH COVERAGE JOIN FORCES

TO ALIGN with Medicare and OPM WITH SHIFT TO VALUE PURCHASING

BUYINGVALUE July 18 2012 Employers Buy Health Care That’s Proven to Work

PRIVATE PURCHASERS OF HEALTH COVERAGE JOIN FORCES

TO ALIGN with Medicare and OPM WITH SHIFT TO VALUE PURCHASING

The World Changed Jan 27th 2012 Insurer WellPoint to revamp primary care

pay January 27, 2012 The Associated Press An Rx? Pay More to Family Doctors WellPoint

to invest 1 Billion in primary care transformation.

“Patient Centered Medical Home” model emphasized in Anthem initiative

UNITED HC see you 10 raise you Conversation with OPM Yesterday - Ways

and Means and what that means

The Foundation: Patient Centered Primary Care

WellPoint strategy will drive transformation to a patient-centered care model by aligning economic incentives and giving primary care physicians the tools they need to thrive in a

value-based reimbursement environment.

Benefit design tied to measurable behavior changes and outcomes

Expanded access through innovation

Aligning care management with the delivery system

Exchange of meaningful information

Four Foundational Pillars

WellPoint - Patient Centered Primary Care (PC2) Strategy – A bold and aggressive plan

This strategy represents an aggressive and fundamental shift in how we interact with and engage primary care physicians on all levels:

clinically, contractually, operationally and culturally.

This strategy represents an aggressive and fundamental shift in how we interact with and engage primary care physicians on all levels:

clinically, contractually, operationally and culturally.

OUR Patient needs A long-term comprehensive relationship with a Personal Physician empowered

with the right tools and linked to their care team.


The Joint Principles: Patient Centered Medical Home Personal physician - each patient has an ongoing relationship with a personal

physician trained to provide first contact, and continuous and comprehensive care

Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients

Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or arranging care with other qualified professionals

Care is coordinated and integrated across all elements of the complex healthcare community- coordination is enabled by registries, information technology, and health information exchanges

Quality and safety are hallmarks of the medical home-

Evidence-based medicine and clinical decision-support tools guide decision-making; Physicians in the practice accept accountability voluntary engagement in performance measurement and improvement

Enhanced access to care is available - systems such as open scheduling, expanded hours, and new communication paths between patients, their personal physician, and practice staff are used

Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home- providers and employers work together to achieve payment reform


Superb Access to Care

Patient Engagement in Care

Clinical Information Systems

Care Coordination

Team Care

Patient Feedback

Publicly Available Information

Defining the Care Centered on Patient


Trajectory to Value Based Purchasing: Achieving Real Care Coordination and Outcome Measurement

34 Copyright 2011 by IBMRegistry Registry

+ +

An opportunity to think and act in new ways—Not master-builder but Master plan DATA DRIVEN

OUTCOMES based!!

From Episode of Care to Population Management at the Personal level -- Centered on the Patient

IntelligentInstrumented Interconnected

=

NJ Patient-Centered Medical Homes Drive Quality and Cost Improvements

152 physicians at 22 practices within ten counties.

Quality Measures 8% higher rate in improved diabetes

control (HbA1c) 6% higher rate in breast cancer screening 6% higher rate in cervical cancer screeningCost and Utilization Indicators 10% lower cost of care (per member per

month) 26% lower rate in er visits 25% lower rate in readmissions 21% lower rate in inpatient admissions

10 April 2012 10 April 2012

2011 Towers Watson Healthcare Cost SurveyBureau Labor Statistics, US DOL 2011 Towers Watson Healthcare Cost SurveyBureau Labor Statistics, US DOL


Savings per employee

$2,830 per employee

$4,025 per employee

$5,486 per employee

$7,264 per employee

$9,420 per employee

18

PCMH level Clinic Competitive Advantage

Expected with Clinic

Expected

Years of PCMH implementation

Annual per employee group health savingsAdvantage grows dramatically over time

10Trained & Engaged

Leadership

10Trained & Engaged

Leadership

8Coordination of care

8Coordination of care

9

Template of the future

9

Template of the future

5Population

Management

5Population

Management

Building Blocks of High-Performing Primary Care April 2012 Center For Excellence in Primary Care

Building Blocks of High-Performing Primary Care April 2012 Center For Excellence in Primary Care

6 Continuity

of care

6 Continuity

of care

7Prompt

access to care

7Prompt

access to care

1 Shared Vision & Goals

1 Shared Vision & Goals

2 Data-driven

Improvement

2 Data-driven

Improvement

3Empanelment & panel size

management

3Empanelment & panel size

management

4Team-based care

4Team-based care

11% CMS Shift in payment away from FFS to other dials.

CMS Bundling!! CMS Advanced Primary Care

Wellpoint PCMH, BCBS Hawaii no new FFS $$

CMS Plus most other buyers CMS Plus most other buyers


Don’t handle your care needs in a BAD MEDICAL NEIGHBORHOOD!!

Unaccountable care, lack of organization, DO NOT GO THERE ALONE !!

Be wise when you pay for care, KNOW WHAT YOU BUY!!


“We don't have a health care delivery system in this country. We have an expensive plethora of uncoordinated, unlinked, micro systems, each performing in ways that too often create sub-optimal performance, both for the overall health care infrastructure and for individual patients." George Halvorson, from “Healthcare Reform Now”

Coordination -- we do NOT know how to play as a team


40

Benefit PlanPaid Claims – Calendar Year 2010

% Total Healthcare

Spend

% of Members

Ten percent of the population consumes 66% of the total spend (members with > $10,000 in expenses)

49% of the population consumes only 4% of the total spend (each spends < $1,000)

So simple!So much!

If you scan the world for value based healthcare, you will find a common element: a relationship-based team with a project manager! A comprehensivist that can command and control in an accountable system.


Public Health Prevention

Specialists

PCMH in Action Vermont “Blueprint” model

Community Care Team

Nurse CoordinatorSocial Workers

DieticiansCommunity Health Workers

Care Coordinators

Public Health Prevention HEALTH WELLNESS

Hospitals

PCMH

PCMH

Health IT Framework

Global Information Framework

Evaluation Framework

Operations

A Coordinated Health System


Vermont Financial Impact

Patientis the center

of theMedical Home

Population Health

Patient-Centered

Care

Refocused Medical TrainingPatient &

Physician Feedback

Advanced IT Systems

Access to Care

Team-Based Healthcare

Delivery

Decision Support Tools

Model adapted from theNNMC Medical Home

Enhancing Health and the Patient Experience

Medical Home Model

Care that is Accountable


PATIENT CENTERED MEDICAL HOME: PATIENT CENTERED MEDICAL HOME: VHA Patient Aligned Care TeamVHA Patient Aligned Care Team

Replaces episodic care based on illness and patient complaints with coordinated care and a

long term healing relationship


Individual Behaviors with Payment and Benefit Reforms

46

Fee for Service Bundled Payments Shared Savings GlobalCapitation

Benefit Plan SteerageTiered networks Tiered networks

Member obligationsTiered networks Gatekeeper

Patient choice of providers

Autonomy Autonomy “Attribution” “Assignment”

Administrative complexity

Well understood by payers and providers

Complex Extremely complex Well understood by some providers and payers

Risk to Providers Minimal Moderate Substantial Substantial

Ability of providers to manage utilization and outcomes

No incentive Substantial within the bundle

Uncertain Substantial across

Support for care management

Minimal at best Built into budget for bundle

Timing issue Supported

Risk to payers

Substantial, even with external UM

Controlled Substantially controlled

Can be totally controlled within the cap budget

According to the study by NEHI, U.S. health care costs are wildly out of alignment with the actual determinants of health. About 50 percent of health status is determined by diet, exercise, smoking, stress and safety—or lifestyle choices and available options; 20 percent by exposure to environmental toxins; 20 percent by genetic predisposition; and just 10 percent by access to health care. Yet the vast majority—88 percent—of Americans’ health dollars are spent on access to care and treatment, with just four percent spent on lifestyle options and choices and eight percent on environmental and genetic factors. This mismatch results in higher and higher costs for less and less health benefit. While many Americans believe that our health care system is the best in the world, the fact is that our health relative to other nations, which spend much less per capita, is slipping, even for survival rates among adults age 45–55.

According to the study by NEHI, U.S. health care costs are wildly out of alignment with the actual determinants of health. About 50 percent of health status is determined by diet, exercise, smoking, stress and safety—or lifestyle choices and available options; 20 percent by exposure to environmental toxins; 20 percent by genetic predisposition; and just 10 percent by access to health care. Yet the vast majority—88 percent—of Americans’ health dollars are spent on access to care and treatment, with just four percent spent on lifestyle options and choices and eight percent on environmental and genetic factors. This mismatch results in higher and higher costs for less and less health benefit. While many Americans believe that our health care system is the best in the world, the fact is that our health relative to other nations, which spend much less per capita, is slipping, even for survival rates among adults age 45–55.

Reinventing Medicaid findings are Outstanding

Oklahoma's patient-centered medical home initiative has reduced Medicaid costs $29 per patient per year from 2008 to 2010. Moreover, use of evidence-based primary care, including screening for breast and cervical cancer, increased.

The Colorado initiative expanded access to care. Before the initiative, only 20 percent of pediatricians in the state accepted Medicaid; as of 2010, 96 percent and did and at a lower cost to the state.

Vermont, inpatient care use and related per-person per-month costs decreased 21 percent and 22 percent, respectively, from July 2008 to October 2010. ER use and related per-person per-month costs decreased 31 percent and 36 percent, respectively.

Patient Centered Medical Home in Washington in State Acute care spending there was 18 percent below the national average. Inpatient stays per beneficiary were 35 percent below the national average.

Source -- M. Takach, "Reinventing Medicaid: State Innovations to Qualify and Pay for Patient-Centered Medical Homes Show Promising Results," Health Affairs, July 2011 30(7):1325–34. Source -- M. Takach, "Reinventing Medicaid: State Innovations to Qualify and Pay for Patient-Centered Medical Homes Show Promising Results," Health Affairs, July 2011 30(7):1325–34.

The Bottom Line in Medicaid PCMH starting to show an impact in access to care, quality, and cost control .

The Bottom Line in Medicaid PCMH starting to show an impact in access to care, quality, and cost control .


PCMH is non-political – the right POV for delivery transformation

“We never abandoned advocating newModels of care. We’ve long pushed folksto realize that Delivery reform is the key.”The patient-centered medical home iscore.

“We included the attached chapter on PCMH in our book. and have a new publication on ACOs coming out in January.”


Source Int’l Federation of Health Plans:2010 Healthcare Price Report Source Int’l Federation of Health Plans:2010 Healthcare Price Report


CAN FRA GER NETH SPA SWIZ UKUS

(avg)

US(95th

%ile)

Appen-dectomy

$3,810 $2,795 $3,285 $4,624 $2,537 $2,570 $3,476 $13,123 $25,344

HipReplace-ment

$10,753 $12,629 $15,329 $12,737 $9,327 $6,683 $9,637 $34,454 $75,369

BypassSurgery

$22,212 $16,325 $27,237 $19,180 $15,802 $11,618 $13,998 $59,770 $126,182

Total Hospital and Physician Costs for Select Surgeries – International Comparisons

Patients love to see meaningful information about themselves and it takes IT tools to If you give patients educational materials with their

name on it and with their data analyzed in it, they will read it, pour over it and discuss it with you.

If you tear off a generic sheet and give it to them, it often goes in the waste basket.

If you give patients an analysis of their health risk AND if you include a “what if” scenario, i.e., what will their health risk be if they make a change; you can prove it to them

“If you the healer make a change, it will make a difference to your patient.”


If we truly want to understand costs and where they can be reduced without compromising outcomes, we need to aggregate costs around the patient. (need a place to do that – that is PCMH)

The way care is currently organized leads to redundant administrative costs, unnecessary and expensive delays in diagnosis and treatment, and unproductive time for physicians.

A system integrator a place where data is aggregated, understood and held accountable at the level of the individual patient -- THAT IS PCMH. In fact, cost reduction will often be associated with better outcomes.

The Big Idea: How to Solve the Cost Crisis in Health Care,Robert S. Kaplan and Michael E. Porter Sept 2011 Harvard Review


ACO and the Principles of the PCMH

Whether building a community-wide ACO or a solo primary care practice, adherence to guiding PRINCIPLES provides the foundation. Through the PCMH Joint Principles, we (the buyers and providers) have agreed to change our covenant with one another. The Joint Principles of the PCMH have been agreed on by those who deliver comprehensive care (the primary care providers) and their specialist colleagues. For Accountable Care to achieve its goals, successful organizations will NEED a foundation in these principles.

As a buyer, I want to be assured that the foundation - the principles - are in place: a personal relationship with a healer, improved access, care that is coordinated, integrated and comprehensive.


PCMH is the patients view from the bottom up. The kind of care they want: relationship, accessible, coordinated

From the System view it is ACO

Or, like the Euro tunnel you can start on one side building PCMH and the other side ACO, but somewhere you have to meet in the middle, where care is delivered- centered on the needs of the patient.



Cost per Case Comparison

16

Savings Gap

Savings Gap Savings

Gap

Savings Gap

$1231 savings per case after contract

implementation


implementation


implementation


implementation

Who was Who was the the Shooter’s Doctor?Shooter’s Doctor?

Away from Away from Episodes of Care - Episodes of Care - FFS FFS

Population management !!

Accountability !!

Population management !!

Accountability !!


Parachute use to prevent death and major trauma related to gravitational challenge; systematic review of randomised controlled trials.

Parachute use to prevent death and major trauma related to gravitational challenge; systematic review of randomised controlled trials.

Smith GC, Pell JP. BMJ 327:1459-1461; 2003.Smith GC, Pell JP. BMJ 327:1459-1461; 2003.

Here is None _ Why ??

Here is None _ Why ??

Paul Grundy, MD, MPH, FACOEM, FACPM IBM Director Healthcare TransformationPresident Patient Centered Primary Care Collaborative

Paul Grundy, MD, MPH, FACOEM, FACPM IBM Director Healthcare TransformationPresident Patient Centered Primary Care Collaborative

NCQA NCQA

Computerworld Solution Honors Laureate

Computerworld Solution Honors Laureate

Dept of State Superior Honor Award

Dept of State Superior Honor Award

ohio aug 2012 (cmprssd)

Health & Medicine

health care industry

experience of care

primary care collaborativetrip

primary care providers

health pay

health costs

docs pcmh

pcmh recognition percent