Baylor Scott&White Quality Alliance: Transforming Population Health

Transcription

1 Baylor Scott&White Quality Alliance: Transforming Population Health October 12, 2015 Michigan Hospital Association Carl Couch, MD MMM President BSWQA 0

2 Today s Discussion BSWH Approach to Industry Population Health BSWQA Update Our Approach to Population Care Informatics and Data Contracts and performance 1

3 BSWH and Industry Overview 2

4 Merger Creates the Largest Not-for- Profit Health Care System In Texas Health Plan/Members Assets Revenues Hospitals Patient Care Sites Licensed Beds Affiliated Physicians Employed Physicians Midlevel Providers Employees Community Benefit 1 / > 240k $8.3B $6.2B ,410 6,000 1, ,000 $867mm Note: All numbers and amounts above are estimates based on the information available to management as of the time of merger on October 1, Baylor system footprint Scott & White system footprint Scott & White Health Plan footprint 3

5 BSWH Mission and Vision Mission Baylor Scott & White Health exists to serve all people by providing personalized health and wellness through exemplary care, education and research as a Christian ministry of healing. Vision To be the most trusted name in giving and receiving safe, quality, compassionate health care. 4 4

6 Our Game Plan: Vision 2020 The Work of our ACO: Baylor Scott&White Quality Alliance VISION

7 The New Winners: Well-capitalized health systems with high functioning, data driven, digitally connected, physician-lead TEAMS delivering evidence-based, patient-centered health care Able to treat higher volumes of patients At lower predictable costs per episode Demonstrating consistent measurable high quality Capable of rapid transformation and consumer awareness. 6 Nate Kaufman, Kaufman Strategic Advisors, LLC

8 Integrated Delivery Network: Build an IT/data analytics platform capable of supporting population health Build the Baylor Scott & White Quality Alliance into a fully integrated delivery network Implement evidence-based protocols for managing chronic disease throughout the network Develop and implement programs to keep people well Improve patient access through partnerships/technology Improve population health and establish the future model for health care delivery in America 7

9 Three Keys to Successfully Delivering Value Under Health Care Reform Eliminate Unnecessary Services Better Manage Chronic Diseases Improve Coordination of Care 8 8

10 So what does all this mean for the patient? Essential for patients to have a medical home. Move to Value Based Payments will change transaction Embrace consumer expectations for encounters via mobile devices and will optionally consult via e-visits and telehealth. Health records will be integrated and easily accessible to patients and every provider visited by the patient. 9

11 So what does all this mean for the patient? THIS YEAR you will be able to stop at a nearby partner retail pharmacy staffed with mid-levels and get preventive and chronic care when it is most convenient for you care that has been proven to be the most effective/efficient. Patients with complex illnesses won t have to visit multiple physician specialists alone nurse navigators will escort patients through the process. Patients will likely get personalized treatment for certain diseases based on a blood sample 10

12 Population Health 11

13 What is Population Health? 12

14 3 Population Health Futures Incremental Population Health Growth Low Risk; Low Opportunity Gradual margin erosion of FFS margin due to Volume declines (caused by reduced utilization) Source: Hogan, Neil, collaboration conference, Washington DC, October

15 Population Health: 2 Mandates Value Value = Quality (+Access) Cost The Triple Aim STEEEP Care The overarching goal for providers, as well as for every other stakeholder, must be improving value for patients Michael E. Porter 14

16 Challenges Complacency Lack of focus Access to capital Non-traditional providers/new entrants into the market Number of uninsured Adequacy of QA network Moving to a retail/consumer oriented model/ e.g., APPS Moving from Fee for Service to Fee for Value 15

17 Have you seen this slide before? 100 Value Based Payments Volume based Payments 0 16

18 Ambidextrous Simultaneous activity Volume Value Excellent FFS care - currently represents >80% of care and majority of BSWH income Value-based care to almost 400,000 patients 17

19 3 Population Health Futures Incremental Population Health Growth Providers at Risk Low Risk; Low Opportunity Gradual margin erosion of FFS margin due to Volume declines (caused by reduced utilization) Tipping Point (30%) Lowered Costs in an integrated system Value wins market share Upsets the Revenue Apple Cart First Mover Advantage Dis-intermediation Source: Hogan, Neil, collaboration conference, Washington DC, October

20 The New Game of Health Care First-Curve to Second-Curve Markets How will health systems successfully navigate the shift from first-curve to second-curve economics? Value-Based Second Curve Payment rewards population value: quality and efficiency Quality impacts reimbursement Volume-Based First Curve Fee-for-service reimbursement High quality not rewarded No shared financial risk Acute inpatient hospital IT investment incentives not seen by hospital Stand-alone care systems can thrive Partnerships with shared risk IT critical for population health management Realigned incentives, encouraged coordination The Future of the Healthcare Marketplace: Playing the New Game, Ian Morrison, PhD 19

21 Competitive Forces: Meet our Newest Competitors Walgreens Aims to Become the Premier Health Destination 2009: Launches flu vaccine campaign 2013: Launches three ACOs (one with SW); begins diagnosing and managing chronic disease Simple Acute Services Vaccinations/ Physicals Chronic Disease Monitoring Chronic Disease Diagnosis/ Management 2007: Acquires Take Care Health Systems 2012: Offers three new chronic disease tests 20

22 3 Population Health Futures Incremental Population Health Growth Low Risk; Low Opportunity Gradual margin erosion of FFS margin due to Volume declines (caused by reduced utilization) Providers at Risk Tipping Point (30%) Lowered Costs in an integrated system Value wins market share Upsets the Revenue Apple Cart First Mover Advantage Consumers Get Cash Consumer Driven Employers and Payers give power of price shopping to consumers (CalPers total Hips) - $30K Source: Hogan, Neil, collaboration conference, Washington DC, October

23 Empowered Consumers 22

24 Reference Pricing 23

25 BSWQA Update 24

26 BSWQA Network: 4,103 Physicians Network Size Category Physician Members NTX Division: 3,050 CTX Division: 1,053 Total 4,103 (PCP 727) 18% (SCP 3,376) 82% Network Accolades Network Footprint North Texas Central Texas NCQA ACO Accreditation Becker s Top 100 SK&A Top 30 ACO 25

27 Accountable December 2015 Can Physicians and hospitals improve quality, reduce cost, and clinically integrate even though it will disrupt current models? 26

28 ACO Components Built Strategic Development Governance Network Development Information Technology Care Management Contracting/ Compensation Mission Vision Culture Strategic financial plan and operating budget developed Physician-led Board of Managers Five primary committees activated Twenty-six subcommittees Network adequacy Credential verification Regional care needs assessment Informatics infrastructure Data analytics implementation Physician dashboard Member website deployment EMR subsidy program dbmotion implementation RN Care Managers Health Coordinators Social Workers PCMH Design Population Health BSW NTX division Employee Health Plan Aetna MA Aetna Whole Health Humana MA Scott & White Health Plan Shared Savings Distribution Model 27

29 A Complete Network Evolve and Continuously Update Network Adequacy Post Acute Care >26 SNF Selected for contracting 10 Home Health Agencies selected for contracting 3 Hospices Children s Hospital Strategy Active discussions and facility commitment for both Dallas and Cook Children s Hospital Physician inclusion likely to be unique for each facility 28 28

30 Our Approach to Population Care 29

31 Population Health Management Six Initiatives Enable physician office directed intervention; PCMH PCMH RN Care Managers for high-risk members Comprehensive Care Management Make clinical and claims data available to those who need it Analytic Capability Evidence-Based Protocols 100+ Protocols Care Plan Integration Wellness Integrate care, starting with Wellness Behavioral Health Address depression and comorbid Mental issues

32 Video highlights of BSWQA key strategies: PCMH Care coordination Data Analytics BSWQA 31

33 The Scalable CI Program Deploying care management resources effectively and efficiently to meet the care needs of the entire population Performance Champions Hot Lists Methods for Promoting Scalability Risk Stratification Predictive Modeling Regional Pods Care Teams (PCMH) Care Coordination 32

34 Clinical Integration Population Health Risk Impending Future Standardization 33

35 Provider Engagement 34

36 Regional Pods Created to better serve physician needs and spread best practices in a more localized and targeted manner Central Target data reporting Northwest North Develop effective contract performance strategies West East Promote team accountability South Share best practices for population health management POD projects with regional hospitals 35

37 Network Field Advisors Engaging Independent Practices NFAs are assigned by Pod Team with physicians/ practice leadership Meet with practices regularly Communicate important BSWQA initiatives Key point of contact 36

38 Opportunity for decision makers to review BSWQA Population Health Contracts JOCs cover key areas of contract performance Network Performance Joint Operations Council (JOC) Network Utilization Management Risk Adjustment Factor Clinical Quality Clinical Efficiency Patient Experience Clinical Integration Contract Access & Review Contract Performance Two rounds of JOC s (1.0, 2.0) completed with the largest practices (based on # of covered lives) within each of the 6 NTX PODs Strategic Initiative review JOC 3.0 begins in October 37

39 Benefits of In-Network Utilization In-Network Utilization Care Coordination IT Perspective Clinical Quality Comprehensive Care Management Department Care Manager Software Cost- Effective Shared EHR Optum One Explorys Patient Portal Shared Protocols/ Quality metrics (driving consistency and best practice Transparency of clinical outcomes BSW NTX employee health plan Plan design incentivizes employees to stay in-network 38

40 Pod Network Utilization Be Aware of where your patients receive care Be Aware of where specialists perform care Be mindful of variations within clinics and look for opportunities between clinic providers 39

41 Wellness Platform - Annual Wellness Visit Proactive customer engagement using a wellness visit business model for population health is BSWQA s catalyst for increased proficiency in managing patient care and further advancement to fee-for-value Annual Wellness Visit Encourages patients to receive comprehensive care No deductible, no copay for the patient Consistent fee-for-service reimbursement HCC code capture for assigning risk Clinical Documentation Improvement opportunity Discovery tool Document illness burden and close gaps before critical events occur 40

42 Complex Care Management 41

43 Complex Care Management Workflow High-Risk (5%) PCP Referrals Risk Stratification Inpatient Transitions RN Care Manager Intervenes by Protocol Review/Revise Care Plan Review/Revise Care Plan Primary Care Physician 42

44 Rapid growth to cover 200K+ lives Current CCM Status Actual 1/1/15 Budgeted for current contracts RN Care Managers Health Coordinators Refining existing practices New Director Embedding care management team members in practices Gaining access to aligned provider EMR and PMS Integrating across the continuum Embedded transition coordinators across the hospital system Integrating with SWHP Post-Acute Care Transition Program Initiated Managing patients transitions from hospital to post-acute care facility 43 43

45 Convenient access to care through dedicated toll-free phone number Find a Baylor Scott & White Quality Alliance primary care physician Schedule appointments Request a referral Bilingual representatives BSW-QLTY 44

46 The BSWQA Difference Post-acute transition program prevents return trip to Emergency Department NOW: Patient avoided visit to the emergency department (ED) and able to remain at their Skilled Nursing Facility after a fall. Patient moved closer to nurses station. Post-acute care RN scheduled a precautionary appointment with an orthopedist for the next day rather than 3 weeks out as suggested. BEFORE: Without the BSWQA post-acute care transition program, the patient would have ended up back in the ED. Before the ACO, transitions from hospital to Skilled Nursing Facilities were often not monitored and patients were left to navigate the transition on their own. BACKGROUND ACO APPROACH OUTCOMES Elderly female patient Complicated hip fracture repair Was non-weight bearing Moderate stages of dimension Discharged from hospital to a Skilled Nursing Facility (SNF) post surgery BSWQA RN Transition Coordinator contacted the patient shortly after their arrival at the SNF to document patient status Patient falls one day after arrival at the SNF Portable x-ray of operative hip was performed. Due to complexity of the repair, x-ray technician requested to view previous films for comparison purposes before determining if the fall warranted a return trip to the ED BSWQA RN Transition Coordinator worked with SNF staff to present the onsite x-ray technician with comprehensive patient information This comprehensive information obtained by the RN Transition Coordinator allowed the x-ray technician to determine that the patient could remain at the SNF and avoid a return trip back to the ED could be avoided 45

47 Informatics and Data 46

48 Reporting and Analytic Activities Physician dashboard with drill-through Administrative dashboard with drill-through Executive Scorecard JOC Physician Engagement Network Utilization with drill-through Predictive Modeling / Risk Stratification 47

49 Analytics and IT Tools Data Aggregation Measure Computation Risk Stratification Physician Dashboards MSSP Quick Reports CMS ACO Measures Exploration/Visualization Claims Analytics Interoperability 48

50 Primary Care Dashboard Physicians have visibility into individual performance 49

51 Specialty Physician Dashboard 50

52 Physician Dashboard Measure & Patient Detail BLUE values in the above table provide additional detail 51

53 Data Driven Network Performance = Analytics to Bedside (A2B) Transparency Engagement Consistency Optimization Variance Reduction Data: You don t know what you don t know Evaluate Goals Develop Best Care Guidelines Measure Performance Against Goals Data Driven Performance Determine Actionable Data Outcome: If you keep doing what you ve always done, you ll get the same outcome you ve always gotten Operationalize Resource Allocation Apply Analytics Build Data Collection Routines 52

54 BSWQA Results 5353

55 Positive Results Heightening Awareness All Cause Re-Admission Rate BSW NTx Employee Plan 20% 10% drop (over two year period) 18% Admissions per Thousand BSW NTx Employee Plan 95 9% drop (over two year period) Day Re-Admission Rate Admissions per Thousand ~ $24M in savings over a 2-year period $ $ $ $ Source: Optum One BSW NTx Employee Health Plan Population Towers Watson Shared Savings Methodology 2013 Target Actual

56 Network Utilization (NUM) Performance 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pre-BSWQA vs. Post-BSWQA Operationalized 66% 57% BSWQA Provider 62% 77% IP at BSWH IP Facility 74% 69% OP at BSWH OP Facility 44% 62% Professional by BSWQA Provider Pre-BSWQA Operationalized ( ) Post-BSWQA Operationalized (2014) A 14% increase in NUM through 2014 resulted in $18.3 million of care being provided by in network facility providers 55 55

57 BSW NTx Employee Plan Medical Cost Reductions PMPM Actual vs. Milliman Medical Index $ % 5% 9% 11% VS. Actual PMPM vs. Target PMPM Trended with Milliman Medical Index Actual PMPM vs. Target PMPM 56 56

58 BSW NTx Employee Plan Medical Cost Reductions PMPM Actual vs. Milliman Medical Index BSW NTx Employee Plan Medical Cost Reductions (PMPM) $ $ $24 million in savings compared to shared savings target $ $ $ $37 million in savings compared to Milliman Medical Index expectation Actual Actual Actual Actual PMPM PMPM Trended with Miliman Medical Index 57

59 The Market is Calling Results create Market Awareness 58

60 Projected Covered Life Growth Value of covered lives being attributed to BSWQA is at a meaningful level driving heightened interest for collaborative agreements 59

61 The Aetna Whole Health BSWQA product continues to be marketed throughout D/FW markets Recent Prospects Status Neiman Marcus Nordstrom Marriott Onsite State Farm Selected Selected In selection process In selection process 60 60

62 Questions/Discussion