shift from healthcare to population health
TRANSCRIPT
The Paradigm Shift from Healthcare to Population Health
Bechara Choucair, M.D.SVP, Safety Net and Community Health
@choucair#PPBmeeting
May 23, 2016
The Practical Playbook National Meeting
2©2016 Trinity Health - Livonia, Mich.
Healthcare trends that affect us all:An urgent need for a paradigm shift
3©2015 Trinity Health - Livonia, MI
U.S. – Spending More for a Shorter Life
The Cost of a Long Life
Per C
apita
Spe
ndin
g
Aver
age
Life
Exp
ecta
ncy
UnitedStatesLife Expectancy Per Capita Spending
(International Dollars)
1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023
1965: $42B1975: $134B
1985: $445B1995: $1T
2005: $2T
2015: $3T
2020: $4.3T
2023: $5.2THistorical Total Expenditures
4©2015 Trinity Health - Livonia, MI
CMS Projects Health Expenditures to Grow at an Average Rate of 5.7%,1.1% Points Faster than GDP Growth
To put this into context, if the 2013 US health care spend of $2.793T was its own country it would be the 6th largest country in the world by GDP, larger than the United Kingdom, Russia, India or Canada
The health spend as a percent of GDP is expected to rise to
19.3%up from 17.2% in 2012
by 2023
5©2015 Trinity Health - Livonia, MI
PerspectivesIf health care costs in Medicare and Medicaid grow over the next 40 years as rapidly as they did over the previous 40 years, those two programs will grow from under 5% of the economy today to 20% of the economy by 2050. That is the entire size of the federal government today and is significantly larger than anything else affecting the federal budget. It is the fundamental long-term fiscal challenge facing this country.
“”— Peter Orszag, former Director of the
Congressional Budget Office (CBO).
"Medicare and Medicaid are the single biggest drivers of the federal deficit and the federal debt by a huge margin."
— President Barack Obama
“Medicare and Medicaid will cost taxpayers roughly $1 trillion this year alone. Unless reforms are enacted, entitlements are on track to consume all tax revenues before today‘s 25 year-olds are eligible for Medicare. The status quo is empirically unsustainable.”
— Congressional Budget Office
There are 76.4 million Baby Boomers according to the U.S. Census Bureau
For each of the next 20 years, 3 million Baby Boomers will reach retirement age
6©2015 Trinity Health - Livonia, MI
The Upside of the Iceberg is Provider’s Opportunity
By 2030, one in five Americans will be a senior citizen and require significant health care services.
7©2015 Trinity Health - Livonia, MI
Costs and Diagnosis of many Chronic Diseases are Expected to Rise Driven in Part by the Baby Boomers Becoming Seniors Between 2011 and 2029.
Hospitals performed twice as many knee replacements surgeries as they did two decades ago with replacement projected to
reach 3.5M per year by 2030 according to a 2012 JAMA study.
By 2029, when the last round of boomers reaches retirement age, the number of Americans 65 or older will climb to more
71 millionup from about 41 million in 2011 according to Census Bureau estimates.
73%increase The number of new cancer cases could
increase 45% by 2030 according to a 2014 ASC Oncology study.
The cost of heart disease in the U.S. will triple by 2030 according to a 2011 study commissioned by the American Heart Association.
More than 50% of Americans could have diabetes or prediabetes by 2020 according to a 2010 UnitedHealth Group study.
8©2016 Trinity Health - Livonia, Mich.
A pivotal transformative moment:The shift to population health is an opportunity we cannot afford to miss
9©2015 Trinity Health - Livonia, MI
The Marketplace Demands Fundamental Change in How We Operate and What We Produce
Producer-Centered
People-Centered
Driv
ers
Retail Health Market
Value Networks
Transparency
Financial Incentives
PopulationValue
ServiceVolume
TOMORROWTODAY
10©2015 Trinity Health - Livonia, MI
Our People-Centered Vision Will Produce the Population Health Dividend – Real Savings from the Triple Aim
Producer-Centered Care
People-Centered Care
Time
Hea
lth C
are
Spe
ndin
g
DIVIDEND
Note: Dividend similar to model cited in “Eliminating Waste in US Health Care.”
Berwick, Donald M., Andrew D. Hackbarth, "Eliminating Waste in US Health Care," JAMA 307, no. 14 (April 11, 2012): 1513-6.
11©2016 Trinity Health - Livonia, Mich.
Trinity Health:We are transitioning to a People-Centered System
30 million peopleWe serve diverse populations, with over
in our communities
As a mission-driven innovative health organization, we will become the national leader in improving the health of our communities and each person we serve. We will be the most trusted health partner for life.
12©2015 Trinity Health - Livonia, MI
Our Vision: What We Aspire to Be … and What We Are Becoming …
Our Mission Drives Our Vision and Strategy
We, Trinity Health, serve together in the spirit of the Gospel as a compassionate and transforming healing presence within our communities.
Our Core Values
ReverenceCommitment to those who
are poorJustice Stewardship Integrity
©2015 Trinity Health - Livonia, MI 13
Building a “People-Centered Health System” together
Better Health • Better Care • Lower Costs
Efficient & effective care management initiatives
Efficient & effective episode delivery
initiatives
Serving those who are poor, other populations, and impacting the social determinants of health
People-Centered Health System
Community Health & Well-being
Population Health Management
Episodic Health Care Management for
Individuals
14©2016 Trinity Health - Livonia, Mich.
15©2015 Trinity Health - Livonia, MI
Building a “People-Centered Health System” Together
Better Health • Better Care • Lower Costs
Efficient & effective care management initiatives
Efficient & effective episode delivery
initiatives
Serving those who are poor, other populations, and
impacting the social determinants of health
People-Centered Health System
Community Health & Well-being
Population Health Management
Episodic Health Care Management for
Individuals
*Owned, managed or in JOAs or JVs.
**Operations are organized into Regional Health Ministries ("RHMs"), each an operating division which maintains a governing body with managerial oversight subject to authorities.
Our 21-State Diversified Network
Home Care & HospiceLocations Serving 116 Counties47
Continuing Care Facilities59PACE CenterLocations14
Hospitals* in 20 Regional Health Ministries**92
Employed Physicians 3.9K
Affiliated Physicians23.9K
16©2016 Trinity Health - Livonia, Mich.
17©2016 Trinity Health - Livonia, Mich.
We operate one of the largest clinical episode payment programs in the nation• 43 Model 2 Bundled Payment for Care Improvement (BPCI) hospitals• 13 Model 3 Skilled Nursing Facilities (SNF)• 2 Comprehensive Joint Replacement (CJR) sites• 22,400 total annual episodes for all three programs
BPCI
SNF
CJR
18©2016 Trinity Health - Livonia, Mich.
We are working to improve care across clinical conditions with 43 of 48 possible bundles
(in millions)Total Program Size: $550m
19©2015 Trinity Health - Livonia, MI
Building a “People-Centered Health System” Together
Better Health • Better Care • Lower Costs
Efficient & effective care management initiatives
Efficient & effective episode delivery
initiatives
Serving those who are poor, other populations, and
impacting the social determinants of health
People-Centered Health System
Community Health & Well-being
Population Health Management
Episodic Health Care Management for
Individuals
We continue to invest in increasing attributed lives and building capabilities
FY14 FY15 FY160
5
10
15
20
25
30
35
$9,000,000
$19,000,000
$29,000,000
$39,000,000
$49,000,000
$59,000,000
$69,000,000
$79,000,000
$89,000,000
FY14 FY15 FY16
Total Number of ACOs, Attributed Livesand Annual Investment
Attributed LivesACOs Annual Investment
Since FY14, Trinity Health has invested over $90M in support of population health management efforts
Investments have promoted continual growth in both MSSP and commercial ACOs
$16.5M
$25.0M$48.9M
34 ACOs
30 ACOs11 ACOs
1,245,7501,121,000
640,000
20©2016 Trinity Health - Livonia, Mich.
21©2016 Trinity Health - Livonia, Mich.
Expanding ACO programs are the primary driver of APM growth• 14 Medicare Shared Savings Program ACOs• 5 markets partnering as a Next Generation ACO • Participating in 98 non-CMS APM contracts• 13.8K physicians participating in our Clinically Integrated Networks
accountable for 1.2 million livesMedicare Shared SavingsNext Gen ACO
Trinity Health made an initial investment in ACOs of $16.5M in FY14
Of the total $44.2M generated, $16.9M of the savings was shared with Trinity Health ACOs
Our initial ACO investments have yielded positive shared savings
Investment in ACOs
Total Savings Generated
Series1
$16.5M$27.3M
Payer Share
$16.9MACO Share
$44.2M
22©2016 Trinity Health - Livonia, Mich.
IT infrastructure and data-driven claims analysis
Combining internal claims data platform and analytic resources with
industry-recognized tools to report provider performance across the enterprise to provider
levels
Standardized care management
process across the continuum
Maximize efficiency in post-
acute and SNF care
Reduce unnecessary or avoidable
hospitalizations
New operating capabilities improve care and lower cost for patients in ACOs
Targeting high risk patients through
predictive modeling and coordinating patient
care through multidisciplinary teams
at the site of care
Identifying clinicians to focus on SNF population
and collaboratively manage transitions
alongside BPCI teams, utilizing home care
partnerships
Improving access to primary and specialty
care providers, engaging hospitalists in adhering
to transitions of care processes
23©2016 Trinity Health - Livonia, Mich.
24©2015 Trinity Health - Livonia, MI
Building a “People-Centered Health System” Together
Better Health • Better Care • Lower Costs
Efficient & effective care management initiatives
Efficient & effective episode delivery
initiatives
Serving those who are poor, other populations, and
impacting the social determinants of health
People-Centered Health System
Community Health & Well-being
Population Health Management
Episodic Health Care Management for
Individuals
Community Engagement:Clinical Services:
Community Health & Well-being
Efficient & Effective Care Delivery through Trinity’s
Safety Net System
Triple Aim Better health Better care Lower costs
Efficient & Effective Wrap Around Services Focusing on the Vulnerable & the Poor
Community Transformation:
Community Building Focusing on Built-Environment Economic
Revitalization, Housing, & other Social Determinants of Health
Innovation in Care DeliveryInnovation in TechnologyInnovation in Financing
Transforming, Healing Presence in the Communities We Serve
©2015 Trinity Health - Livonia, MI 25
Community Engagement:Clinical Services:
Community Health & Well-being
Efficient & Effective Care Delivery through Trinity’s
Safety Net System
Triple Aim Better health Better care Lower costs
Efficient & Effective Wrap Around Services Focusing on the Vulnerable & the Poor
Community Transformation:
Community Building Focusing on Built-Environment Economic
Revitalization, Housing, & other Social Determinants of Health
Innovation in Care DeliveryInnovation in TechnologyInnovation in Financing
Transforming, Healing Presence in the Communities We Serve
©2015 Trinity Health - Livonia, MI 26
Dual eligible beneficiaries are among the poorest and sickest beneficiaries covered by either program.
Most have multiple chronic conditions.
Nearly half have significant mental illnesses.
In 2013, over 10.7 million individuals were dually eligible for Medicare and Medicaid benefits.
Transforming Safety Net Care with a Focus on the Duals
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©2014 Trinity Health. All Rights Reserved. 28Innovation Council - Internal ©2015 Trinity Health - Livonia, MI
Nationally, Duals accounted for a total of $284.5B in spending in FY ’10. Today, spending is estimated to exceed $300B.
Spending on the “Duals” accounts for approximately 2% of GDP.
Trinity Health provides care to more than 207k Dual-eligible patients, representing $1.5 Billion in acute care revenue, annually.
©2015 Trinity Health - Livonia, MI 28
Spending on Dual-eligible Patients is High
Innovation Program – Internal @2016 Trinity Health – Livonia, MI 28
29©2015 Trinity Health - Livonia, Mich.
http://trinityhealthchallenges.org
May 2, 2016 Challenge launch
June 10, 2016 Letter of Inquiry (LOI) deadline
July 15, 2016 Notify if invited to complete an application
August 19, 2016 Application deadline
September 26, 2016 Innovation Council meeting/ virtual showcase
October 15, 2016 Announce awards!
3030
Challenge Timeline
©2016 Trinity Health - Livonia, Mich.
Community Engagement:Clinical Services:
Community Health & Well-being
Efficient & Effective Care Delivery through Trinity’s
Safety Net System
Triple Aim Better health Better care Lower costs
Efficient & Effective Wrap Around Services Focusing on the Vulnerable & the Poor
Community Transformation:
Community Building Focusing on Built-Environment Economic
Revitalization, Housing, & other Social Determinants of Health
Innovation in Care DeliveryInnovation in TechnologyInnovation in Financing
Transforming, Healing Presence in the Communities We Serve
©2015 Trinity Health - Livonia, MI 31
32©2015 Trinity Health - Livonia, MI
What Drives Good Health Outcomes? Access and Quality of Care ≈ 20%
Self-Referral or by Family
or FriendHomeless
Shelter
Community Transport Services
Independent Physicians
Our Desired Future:Better Health, Better Care, Lower Cost
33
Inpatient Acute Care
Continuing Care
EDEmployed & Independent Physicians
HUBCHWs &
Data
Medication Assistance
Insurance Enrollment
Pregnancy Assistance
Social Services
Care Management Programs
(e.g., Faith Nursing; Complex Care)
Integrated Delivery Network
NOTE: Examples of HUB services. Many
others are sponsored by the community/RHM.
Nature of our Ministry:Community at Large (501r)
Behavioral Health
Social Determinants(e.g., Race/Ethnicity,
Gender, Income Level, Language, Literacy, Living
Location)
Data DataACOSample Referral Sources
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34©2015 Trinity Health - Livonia, MI
We Can Make a Real Difference in Patients’ Lives
Muskegon Health ProjectPathways to a Healthy Pregnancy Muskegon, MI
Katrena H.Patient
Ka’Ziya H.Baby&
Pre-Community Health Worker Involvement
• Homeless• High-risk
pregnancy• Needing
prenatal care
Post-Community Health Worker Involvement
• Has housing and resources for new home
• Received prenatal care• Delivered a healthy baby
Before we met you, we were homeless and we were going from place to place.“ ”- Katrena H.
Deployment of 50 Community Health Coordinators
Part of a 2015 AmeriCorps Partnership
Challenge Grant
Community Health
Workers
Up to 10 CHWs
deployed in each targeted
MSSP and BPCI program
Focus on the Duals
Advanced analytics to
identify highest-risk
patients
Deploy CHWs & HUB / Pathways
Model to address social needs
Community Engagement
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Measuring ImpactExisting MSSP ACO metrics / dashboards will be used to evaluate the impact of deploying up to 10 CHW at each of the 6 targeted ACOs.
©2015 Trinity Health - Livonia, MI 36
Community Engagement:Clinical Services:
Community Health & Well-being
Efficient & Effective Care Delivery through Trinity’s
Safety Net System
Triple Aim Better health Better care Lower costs
Efficient & Effective Wrap Around Services Focusing on the Vulnerable & the Poor
Community Transformation:
Community Building Focusing on Built-Environment Economic
Revitalization, Housing, & other Social Determinants of Health
Innovation in Care DeliveryInnovation in TechnologyInnovation in Financing
Transforming, Healing Presence in the Communities We Serve
©2015 Trinity Health - Livonia, MI 37
Health Does Not Begin In A Doctors Office…
Access to healthy and affordable food
Built-environment
Race / Ethnicity
Economic opportunity
Educational opportunity
Root Causes of Good vs. Poor Health
Safe places for kids to learn and play
Food and beverage environment in schools
Socioeconomic status / Income
Other social determinants of health
Clinical care (just the tip of the iceberg)
©2015 Trinity Health - Livonia, MI 38
39©2015 Trinity Health - Livonia, MI
Anticipated investment of $80 million over 5 years in community health interventions.
Funding local partners with Several national partners at the table.
Applications are led by Community Coalitions, Local public health agencies & Trinity Health Ministries
$17.5 M
$22.
5 M
$40 M
Transforming Communities Funding OpportunityLaunched in Nov 2015
40©2015 Trinity Health - Livonia, Mich.
• Boise, ID (Promise Partnership)
• Maywood, IL (Proviso Partners for Health)
• Silver Spring, MD (Healthy Montgomery)
• Springfield, MA (Live Well Springfield TCI Partnership)
• Syracuse, NY (Syracuse Health Coalition)
• Trenton, NJ (Trenton Health Team)
Six Communities Selected to Be Funded:
41©2015 Trinity Health - Livonia, Mich.
• Implementation of Tobacco 21 policy
• Development/ implementation of Complete Streets Policies
• Implementation of Nutrition Standards in Head-start & Daycare
• Enhancement of Breastfeeding Policies
• Expanding Physical Activity School Board Policies
• Implementing Food and Beverage Standards/Policies in Schools
Select Strategies to be Implemented Across all Six Communities
42©2015 Trinity Health - Livonia, Mich.
Tobacco policy work is integral to our Community Health and Well-Being strategy.
The longevity gaps in America are growing, not shrinking.
CDC researchers have concluded disparities in tobacco use account for 20% to one-third of growing life expectancy gaps.
Living in locations that have not adopted strong tobacco control measures is directly correlated with growing health disparities and longevity gaps.
Our commitment to vulnerable populations, especially people who are poor, demands action.
43©2015 Trinity Health - Livonia, MI
Our Tobacco Policy Focus
• Pass and/or Strengthen Clean Indoor Air Laws
• Tobacco Free Campus Policies
• Tobacco 21: Raising the Legal Purchase Age to 21
Community Transformation
©2016 Trinity Health - Livonia, MI
44
of Americans live in states with strong state-level protections. Everyone else relies on local governments to close the gap, or must advocate for state-level changes.
53%
Source: Americans for Non-Smokers Rights.
6 States In Our Network Diversified Network
Loopholes for many workplaces and bars
Loopholes for bars
Loopholes for barsand restaurants
No state law!
states within our footprint have weak clean indoor air laws for combustible cigarettes6
Strong state law
A Patch-Work Quilt of SmokeFree Laws Leave Many Behind
Institute of MedicineTobacco 21 Will Reduce Smoking and Save Lives
©2015 Trinity Health - Livonia, MI 46
decline in smoking initiation by 15-17 year olds
25% overall drop in smoking prevalence
12% reduction of smoking related deaths
10%
For kids alive today, 4.2 million years of life would be saved by virtue of this logical, simple policy change.
Other Important Impacts…
Decline in premature births12% Drop in SIDS cases16%
©2015 Trinity Health - Livonia, MI
Tobacco 21: Over time…
47©2015 Trinity Health - Livonia, Mich.
In 2016, alone, we’ve experienced big wins in many of the communities we serve.
• January 11: New Jersey passed Tobacco 21 law (pocket veto)
• March 16: Chicago passes Tobacco 21 and other historic measures
• March 29: South Bend passes state’s strongest smoking ban
• April 12: Washington, D.C. Congressional briefing likely to result in several additional co-sponsors on Federal legislation
• April 26: Albany County passed Tobacco 21 (bill not yet signed)
• May 10: California Tobacco 21 and other historic bills signed into law
• May 18: Illinois Tobacco 21 passed out of the Senate
Building a “People-Centered Health System” together
Better Health • Better Care • Lower Costs
Efficient & effective care management initiatives
Efficient & effective episode delivery
initiatives
Serving those who are poor, other populations, and impacting the social determinants of health
People-Centered Health System
Community Health & Well-being
Population Health Management
Episodic Health Care Management for
Individuals
48©2016 Trinity Health - Livonia, Mich.
Discussion…
@choucair#PPBmeeting