Public Health Workforce Summit

Health System Redesign and Payment Reform

Setting the Stage for Modernizing the Public Health

Workforce

Anthony Rodgers, Principal

Health

December 13, 2012

The ACA Created the Policy Framework for

the US Health Reform Process

Health Insurance

Reform

Healthcare Delivery System

Transformation

Payment Reform &

Value Based Purchasing

2

Affordable Care Act

“However, successful health reform and

specifically delivery system redesign and payment

reform requires leadership and an intelligent

designer.”

Healthcare Eco-Sphere: Key

Attributes

Regulatory

Climate Competitors

Economic

Trends Health Care

Delivery Systems

• Pop. Growth

•Aging Pop.

•Health Status

•Insurance

Reform

•Medicare

•Medicaid

•Major health

plans

Medicare Plans

CO-OP Plans

ACOs and

Systems

•Econ Growth

•Job Creation

•% of Small Bus.

•Unemployment

rates

•Consolidation

•Level of

Integration

• Overall

Capacity

Design Requirements for Intelligent Healthcare System Design and Payment Alignment

Health

Plans

Hospital

Networks Providers

Consumer

Expectations

Public

Payers

Market

Mix

•Med. cost

Inflation

•Premiums

•Provider supply

• Coverage Options

•Provider

Relationships

•Reimbursement

•Network Models

• Operational Costs

•Capacity/Distribution

•Cost of Practice

•Malpractice cost

•Level of Integration

•Choice

•Control

•Safety

•Information

•Affordability

•Cost Containment

•.Quality of Care

•Accountability

Processes

• Admin. Cost

•Public Sector

• Private Sector

• Uninsured

Impact

Broad Strategies &

Transformative

Solutions:

Finding

Solution

Synergies

Common

Goals &

Solutions

Medical

Cost Tends

•Reimbursement

Rates

•Utilization (+)

•Drug and Tech

Trend

MLR

Human

Resources

•MD

•Nursing

•Other

The Macro Environmental Scan of the Healthcare Delivery System

Private Sector Public Sector

The Challenge

The Healthcare System is made up of a multitude of complex and

interconnect health deliver system performance influencers,

cost drivers, and dependent relationships

that make up the health care eco-system

The Affordable Care Act

Created the Opportunity for Continuous Healthcare Coverage “This provides a economic rationale for investing in optimizing long term health”

Design Question: Can a health system be designed that can

address the factors shaping the health of the population

and a healthy lifespan trajectories?

Age

Hot Spot/High Risk

Communities

and Population

Optimal

Health

Current Health

System Results

Fair

Healt

h S

tatu

s

Fair

Health

Poor

Infant Adolescents Adult Senior

Future Transformed

Health

System Results

It must

start here!

Not Here!!

Health System

Performance

Black Box

Quality of Care

Co

st

of

Ca

re

Design Challenge

To Create

Organized

Accountable

Healthcare

Networks that

have the capacity

to manage

all the factors that

contribute to

patient health and

wellness

Micro Level Patient Care Black Box

The Patient Centered Behaviors

of the Transformed Healthcare System

Informed,

Activated

Patient

Productive

Interactions

Prepared and

Integrate

Clinical

Team

Electronic Health Record & HIE

Clinical and Patient Care

Management Decision

Support Tools

Community

Integrated

Service

Support System

Community

Healthy Living

& Self

Management

Support

Community

Health

Performance

Black Box

Life Span Health &

Prevention Effectiveness

Po

pu

lati

on

Co

st

of

Ca

re

Design Challenge:

To create

community

centered and

accountable

healthcare

networks that can

address all the

factors that

contribute to

community/

population health

Macro Level The Black Box of Population and Community Health

Preventive

Care

Acute

Care

Chronic

Care Screening

Services

Community Centered

Health System Behavior

Comprehensive Health Care,

Screening, and Prevention

Community

Surveillance Community

Engagement and

Governance

Assessment

& Referral

Resources

Community Based

Governance

Assessment

Process

Community

Trust

Programs

Community

Services and

Resources

For

Special Needs

Other

Specialized

Services

Community Healthy

Living Support and

Environment

ACO Network

Medical

Home

Specialty

Consults

Lab Work/

Imaging

Hospital

Stay

Multi-Payer Public and Private Health Plans

Physician

Practice/

ACO

ACO Adjusted Global Payment with an Additional Quality and Population

Health Improvement Incentive Payment to Incent

Community Centered Behavior

Avoidable Avoidable

Avoidable

$

$

Community Risk

Condition- Adjusted

Per Person Payment

Office

Visits

Care

Mgmt

Patient

Support

P4P Outcome Bonus/Penalty Based on Quality & Population

$ $

What is the adjusted payment value

for population/community health risk?

Cost Savings

Accrues to

the ACO

Network $ Add Population Health or

Community Risk

Adjustment and Incentives

What are Examples of Community Centered Health System Behaviors?

Community

Centered

Areas of Focus

Actions Examples of Outcomes

Promote Early

Childhood

Development

Provider Network integrates resources and supports develop quality

early childhood resources,

Collaborative action with Child Development and Elementary

Schools

Support earlier reading

Support parenting classes

Link with and support early intervention for high risk children and

families.

Reduced drop out rate

Healthier Children and Adolescents

Reduction of teen-age pregnancies

Promote Good Family

Nutrition

Work with grocery stores and local farmers to make healthy food

choice available

Support WIC

Raise healthy food awareness and health literacy awareness

Better birth weight

Reduction of Child hood obesity

Improved behavior in school

Promote Community

Healthy Living

Support work place safety programs

Support adequate and environmental safe housing

Build community capacity for health, fitness, and recreational resources

Healthier seniors c

Healthier children

Reduce work place injuries

Reduce substance abuse

Healthy Workforce Support and integrate with workplace wellness programs

Make primary care more available after work hours

Develop employee specific healthy living strategies

Reduction of work place injuries

Improved overall employee health

Reduce worker absenteeism

Safe Community Improve community safety

Identification and early intervention regarding high risk behaviors

among youth and adults

Support increase lightening and safe recreation areas

Reduction of crime

Reduction in juvenile detention cost

Reduction of trauma and domestic

violence

11

12

Patient to Population Accountable Care Network Community Health Oriented Performance Measures

NQF

Delivery

System

Health

Measures

Patient

Specific Value

Based

Outcomes

Performance

Screen

Community Value

Based Performance

Measures

• Adult smokers

• SBIRT screening

•Depression Mgmt

•Teenage Pregnancy

Rates

•ADL Scores

•Immunization rates

•EPSDT screening

rates

•BMI

•Domestic Violence

“Patient High Risk”

measures

Community

Dashboard

Public Reporting

Community

Performance

Priorities

Community or Population

Specific Performance Indicators

Cost, Quality

and Population

Health VBP

Payment

Based

Performance

Reduction in

Community

Risk Factors

Patient Performance

Reporting System

MD MSW

CHT

HE PNP

MD MSW

CHT

HE PNP

Intelligent Health System and Payment Reform Design

Community Centered

•Population Health Trajectories •Diagnosis-specific outcomes •Geographic Outcomes •Community Healthy Living Outcomes •Short/Long Term Benefits and Costs Savings

Performance Accountability Mechanisms

•Decision Support and care mgmt •Quality , Cost, and Population Health Performance •Clinical & Population Registries (surveillance and other analyses) •Health information exchanges •Community Reinvestment

Community Integrated Delivery Mechanism

Integrated Finance Mechanism •Employer •Medicaid CHIP, Medicare •Individual •Community Health Trust Fund •Other: Title V, Head Start, Title X, CDC, etc

Health Benefit Financed Population Health Financed

Patient Care Reimbursement Community & Life Span Health

HIE SS EI LTC

Community Resources

PRC

Primary Care Center

Accountable Care

Networks Primary Care

Network

MD MD

MD MD

MD

Community Living Resource Center

REPORTS

SPECIALIST

H SPECIALIST

H SPECIALIST

H

SPECIALIST

H

SPECIALIST

H

Community

Health

Data

Community

Dashboards &

Public Reports

Who will Be the Intelligent

Designer of a Transformed

Health System?

14

States as Laboratories for Intelligently Designed and

Reimbursed Healthcare Delivery Systems

Health System

Transformation

Policy Alignment

Delivery System Design

Payment

Models

Health

IT

Performance

Improvement

Accountability

Incentives

Episode of

Care

Bundles

Global

Payment etc.

Models

Medical/Health

Homes

ACO’s

IDSN’s

CCO

Performance

Management

Performance

Reporting

Provider

Profiling

QI/PI

Population and

Community

Health

Policies

GME Policy

Public Health

Workforce

Community Dev.

HEALTH SYSTEM EVOLUTION

ROADMAP

INTELLIGENT DESIGN:

BY INTEGRATING STATE and FEDERAL DELIVERY SYSTEM

and COMMUNITY HEALTH INITIATIVES TO ACHIEVE IMPROVED QUALITY, POPULATION HEALTH and LOWER

HEALTH CARE COST

2013 2012 2015 2014 2016

HEALTH CARE DELIVERY EVOLUTION

HEALTH

SYSTEM &

PROVIDER

REALIGNMENT

IMPROVED

PATIENT

CARE

MANAGEMENT

COMMMUNITY

HEALTH

INTEGRATION

IMPROVED

PATIENT SELF

MANGEMENT EXPANSION

OF HIT AND

EHR

COST QUALTY

PERFORMANCE

TRANSPARENCY CLINICAL

INTEGRATION

OF CARE

LIINKAGE

WITH

COMMUNITY

REOOURCES

Healthcare System 1.0

HIGH COST

INFLATION

LOWER

HEALTHCARE

COST

INFLATION

2.0%

2.5%

3.0%

3.5%

4.0%

Healthcare System 2.0 Healthcare System 3.0

The Challenge:

For someone to put all the puzzle pieces

of the ACA together and make the

promise of health reform a reality.

February 26, 2013