Fixing Health Care s Broken System Richard F. Multack DO, FOCOO, MBA Vice President of Medical Management Advocate South Suburban Hospital

Transcription

1 Population Health Management The response to, Fixing Health Care s Broken System Richard F. Multack DO, FOCOO, MBA Vice President of Medical Management Advocate South Suburban Hospital

2

3 3 Please don t worry

4 The Way We Were

5 How did we get here? 1. Unsustainable growth of health cost 2. Growing lack of access to healthcare 3. Disparities in care

6

7 Who s driving up U.S. healthcare costs? A recent study by Harvard professors and colleagues revealed that the culprits may be cowboy doctors physicians who provide intensive, unnecessary, and often ineffective patient care, resulting in wasteful spending costing as much as 2 percent of the nation s Gross Domestic Product hundreds of billions of dollars annually.

8 We were Confused

9 We lacked direction

10 Sometimes you need to pick a different road

11 The best way to deal with the future is to create it Abraham Lincoln

12 What have we done? 1. HITECH ACT (American Recovery and Reinvestment Act of 2009) 2. Patient Protection and Affordable Care Act of 2010 Pay 4 Performance Patient Centered Medical Home Payment Bundling Shared Savings / ACO Value Based Purchasing Hospital penalty for Readmissions, and other quality issues such as HACs

13 Medicare Physician Payment Medicare Access and CHIP Reauthorization Act of 2015 Replaces the dreaded Sustainable Growth Rate Beginning in 2019 establishes two payment tracks for physicians Those in alternative payment models (APM) All others in MERIT BASED INCENTIVE PAYMENT SYSTEMS (MIPS)

14 Merit Based Incentive Payment System (MIPS) Sunsets existing payment programs: PQRS, VBM, EHR meaningful use CMS will incorporate these measures and develop methodology for assessing performance Physician performance will determine annual payment adjustor

15 MIPS There will be a Composite Threshold Performance Scale (0 100) The system will award bonuses and impose penalties based on whether physicians score above or below a certain threshold on quality measures, including meeting the requirements for the meaningful use of health IT. Reimbursement will actually be based on; Meaningful Use Quality measures Clinical Practice Improvement Activities

16 MIPS Four (4) performance categories 25Pts MU of CHERT 15Pts Clinical Practice Improvement 30Pts VBM measured quality 10Pts VBM measured resource use First Performance Measure Year 2017 First likely payment adjustments 2019

17 External Pressure on Physicians Core Measures ICD-9-CM ICD-10 MD and Hospital Quality Reports POA HACs PSIs Preventable Readmission Complications Value Base Purchasing Care Coordination Team Medical Necessity Compliance Fraud Abuse RAC 2 MIDNIGHT RULE E&M Pro fees Denial related claims

18 On top of all that then they gave us ICD 10

19

20 M community $661 M community benefit

21 Key Market Dynamics Provider consolidation Dominant health plans Narrow networks emerging Revenue - utilization and price Cost pressures Anthem has agreed to acquire Cigna in a $54 billion merger of health insurance giants. The companies said that Anthem, Inc., a Blue Cross and Blue Shield insurer, would buy all of Cigna Corp.'s shares in a cash and stock transaction. The latest step in a striking consolidation of the insurance industry would leave only three major players. Earlier this month, Aetna struck a deal to buy Humana for $37 billion.

22 Strong Alignment Values Top decile safety and quality Strong brands Highly integrated Large employed medical groups Strong management and governance Excellent teaching and research Double A ratings

23 Changing Business Model Providers traditionally generate revenue by: Maximizing rates Maximizing volumes (churning) Which is changing to a new model Taking financial risk for managing the health of a population, lowering costs and serve a greater number of unique patients

24 Advancing Commercial Approach Extension of Blue Cross shared savings and global capitation contracts Shared Savings ACO contracts United CIGNA Others

25 Medicaid Managed Care Illinois requires 50%+ of Medicaid population be enrolled in: Accountable Care Entities (ACE) Medicaid HMOs Cook County Demonstration Medicaid ACE is fee for service with a care management fee until Jan. 1, 2016

26 Why did they do it? The overarching purpose of these changes is to move away from fee for service, which is regarded as a major driver of the nations health cost To a model of greater responsibility and accountability. This approach is called Population Health management

27 What is it? Population Health management is defined as, controlling the health outcomes of a group of individuals. This includes, Public health intervention Social environment Income Education Employment Social support Cultural factors

28 What is it? Includes, Aspects of the physical environment Urban design Clean air Clean water Genetics Behavioral Health Psychiatric conditions Addiction

29 The Continuum of Care Pre Hospital Hospital Post Acute Care Ambulatory Outpatient Inpatient Physician Practices Ambulatory Surgery Ctr OP Facility/ Comprehensive OP Rehab Fac. Critical Access Hospital Outpatient Critical Access Hospital Inpatient Skilled Nursing Facility Population at Risk Urgent Care Ctr Fed Qualified HC Employer Clinic Home Health Agency Retail Clinic Free-standing Diagnosis Center Indian Health Services Community Mental Health Clinic Rural Health Clinic Hospital - Outpatient Day Surgeries Emergency Clinic visits Observation Hospital Based ancillary services Hospital Inpatient Psych Inpatient Rehab Hospice Home Hospice Home Healthcare Physician Office Clinic End Stage Renal Disease Physician Evaluation and Management

30 Goal of Population Health Management The goal of population health management is to keep a patient population as healthy as possible, minimizing the need for expensive interventions such as emergency room visits, hospitalizations, imaging, testing and unnecessary procedures. Although focused on the sickest patients initially PHM addresses the preventive and chronic care needs of the population. We know that distribution of healthcare risk changes over time, the object is to modify the factors that make people sick or exacerbate their illness.

31 Care Management Supports the Patient Continuum Primary Care Access Primary Care Access, Team Model of Care ECM Outpatient CM ECM Inpatient CM ECM Outpatient CM Strong Relationship and Communication Post Acute Post acute SNF Network/Model Transition coaches Advocate At Home Palliative Care

32 Methodology Data Collection, storage and management = EMR Population Monitoring and Stratification = Statisticians Patient engagement Team based intervention Measuring outcomes

33 Methodology Population health management requires healthcare providers to develop new skill sets and new infrastructure for delivering care

34 Reimbursement Today

35 2020 Outlook

36 From Fill the Hospital to Empty the Hospital

37 POPULATION MANAGEMENT

38 So how are we going to actually manage the population? 24/7 Access to office or ambulatory acute care setting Same day appointments Medical Home Narrow networks Integrated care keep it in the system Clinical Effectiveness carve out waste Decreasing pre op testing Stopping unnecessary and obsolete lab testing Stopping unnecessary imaging and procedures Appropriate use of blood transfusions Standardization of equipment and procedures such as total hips leveraging economies of scale for better vendor pricing

39 So how are we going to actually manage the population? 24/7 Access to office or acute care setting Same day appointments Medical Home Narrow networks Integrated care keep it in the system Extensive social support Care management Social work Integrated home health Integrated PAN network Behavioral health Patient engagement

40 ACO Value Structure: Wrap Around Care Continuum Aligned Goals, Strong Relationship and Communication = Patient/PCP Value Community Agencies/Programs Post Acute Network SNF Post Acute Network Advocate At Home Palliative Care Outpatient Care Management Dedicated Outpatient CMs Multi condition centers Patient /PCP Transitions Emergency / Acute Care Management Inpatient CMs ED CMs Hospitalists Patient/Family Education and Support

41

42 Summary Conclusions Better life style Preventive care Appropriate care Integrated care Home Care Skilled nursing care Appropriate end of life care

43 References Advocate Health Care, MPAK Health Care s Perfect Storm Leadership Development Institute Quarter Advocate Health Care, Physician Leadership Development Day 2015, June 19, 2015, Strategies to Whether The Storm, Lee Sack, MD CMO Advocate Health Care The Changing Face of Medicine What s In It For Me Richard F. Multack, DO, VPMM, ASSH (2013) The Changing Face of Medicine 2014 and Beyond Richard F. Multack, DO, VPMM ASSH (2014) Kindig D, Stoddart G. What is population health? ( American Journal of Public Health 2003 Mar;93(3):380 3 Retrieved Howe, Rufus, and Christopher Spence. Population health management: Healthways Pop Works ( E74 A5C9 E1973F5ABC05.pdf). HCT Project , volume 2, chapter 5, pages Retrieved Coughlin JF, Pope J, Leedle BR. Old age, new technology, and future innovations in disease management and home health care ( Home Health Care Management & Practice 2006 Apr; 18 (3): Retrieved DMAA: The Care Continuum Alliance. Publications. Population Health management ( Retrieved Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ (May 27, 2006) Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data ( (PDF). The Lancet 367 (9524): Doi: /SO (06) ( 6736%2806% ). PMID ( Congressional Budget Office, May 2013 Estimates of the Effects of the Affordable Care Act on Health Insurance Coverage CDC/NCHS National Ambulatory Medical Care Survey Primary Care Shortages could be Eliminated Through Use of Teams, Nonphysicians and Electronic Communication Health Affairs 32 1 Jan 2013 Michael E. Porter and Thomas H. Lee, The Strategy That Will Fix Health Care, HBR October 2013 Kaiser Family Foundation, 2012 Employer Health Benefits Survey