1 EVENT SUMMARY Phytel Executive Summit Population Health Management Strategies and Tactics towards Accountable Care and Population Health Healthcare success requires a proven and scalable approach to population health management in order to succeed in the new world of accountability, quality, and value
2 Contents Introduction...3 Patient-Centered Medical Home as Core Tenet of Population Health... 4 Paul Grundy, MD, Patient-Centered Primary Care Collaborative Lessons Learned on Journey to Population Health Management and Employer Alignment...5 Ashok Rai, MD, Prevea Health Achieving High Quality, Low Cost Care in a Changing Environment... 6 Cliff Fullerton, MD, Baylor Health and Health Texas Provider Network Hard-Wiring the Primary Care Practice for Success in a Value-Based Environment...7 Sharon Lucie and Lindsay Gainer, RN, North Shore Physicians Group Building Successful Clinical Integration Across the Continuum... 8 Rick Warren, Allegiance Health; Allana Cummings, Northeast Georgia Physicians Group; Renee Broadbent, Accountable Care Associates, LLC Applying Data Analytics to Manage Population Health...9 Farzad Mostashari, MD, Office of the National Coordinator for Health Information Technology (ONC) Accelerating Health Care Transformation...10 Ray King, MD, Allegiance Health; Wynn Hazen, Jackson Health Network Before You Click Creating an Information-Centered Culture...11 Donald Lurye, MD, Elmhurst Clinic Day in the Life of a CMO: Managing a Contract for Diabetes...12 Richard Hodach, MD, and Russell Olsen, Phytel Accountable Care: Combining Claims-Based Risk Management with Enterprise Care Management...13 Matt Siegel, MBA, Verisk; Marina Pascali, PhD, Phytel The Future of Bundled Payments and Shared Savings within ACOs...14 Don Fisher, PhD, American Medical Group Association Experiences of Advanced Integration Systems in Population Health Management...15 Michael Matthews, MPH, InHealth and MedVirginia Behavior Change and Patient Engagement and Activism...16 Karen Handmaker, MPP, and Michele Hallman, RN, Phytel 2
3 Introduction More than 100 participants from 43 healthcare organizations attended the first annual Phytel Executive Summit in Dallas from December 3-5, One important participant, Farzad Mostashari, MD, the national coordinator of health information technology, attended the conference remotely, making a video presentation that received a very warm response. In his opening remarks, Phytel CEO Steve Schelhammer pointed out that this is an unprecedented time in healthcare. As healthcare costs grow faster than the capacity of the national economy to sustain them, it s clear to everyone that we need a better way to deliver high-quality, affordable healthcare. By leveraging digital data and technology, healthcare providers can now manage population health cost effectively, making it possible to lower costs by keeping people healthy. The new care delivery models require new workflows, and new electronic tools are needed to automate those workflows, Schelhammer noted. Moreover, these trends are accelerating because of the pace at which providers are forming accountable care organizations and payers are signing risk contracts with them. The conference addressed a number of aspects of the new approaches to healthcare delivery and the electronic solutions that have been developed to support them. Among the topics discussed were patient-centered medical homes, accountable care organizations, bundled payments, the automation of care management, clinical integration, care teams, data analytics, patient engagement, community involvement in population health management, physician culture, risk management, and the integration of claims and clinical data in care management. By leveraging digital data and technology, healthcare providers can now manage population health cost effectively, making it possible to lower costs by keeping people healthy. 3
4 Presenter: Paul Grundy, MD, global director of healthcare transformation, IBM, and president, Patient-Centered Primary Care Collaborative Patient-Centered Medical Home as Core Tenet of Population Health In an era of healthcare transformation, patient-centered medical homes (PCMHs) are the agents of change. They have proven their value and are being widely embraced across the country. At last count, the number of PCMH sites had risen to 4,669 with 22,059 clinicians. One reason why we need the PCMH is that it supports primary care. According to a recent Institute of Medicine report, Primary care providers are the only healthcare professionals who can affect change in healthcare. Referring to the Triple Aim of the Institute for Healthcare Improvement (improved quality, lower costs, and better patient experience), the report said, The systems and structures that will fulfill the Triple Aim can only be designed and implemented by primary healthcare healers. In addition, the PCMH focuses on population health management, which is the key to healthcare transformation. If you manage the population better upstream, you reduce the use of hospital beds for ambulatory-sensitive conditions. This is better quality care, and it costs less than today s healthcare does. The current healthcare system has the wrong approach. For example, hospitals put up billboards with slogans like we do the best heart surgeries. They boast about the quality of their procedures, not about their ability to keep people healthy. To change this attitude, we must change our payment and delivery systems, and providers have to engage patients differently. Data is going to drive these changes in healthcare. We tried managed care before, but it wasn t successful because we didn t have the data. Now we do have the data, plus the analytics and the computing power to apply it and make it actionable. In the future, with the aid of data, every patient is going to have a care plan. Every patient in the population is going to be managed, and the care management will be accomplished using care teams. This is already beginning to happen in PCMHs, which coordinate care far better than conventional primary care ever did. The results are just starting to emerge in the literature, but some benefits are already apparent. In one Midwestern healthcare system, for example, per employee per month health costs dropped from $805 to $569 after the system s primary care practices became PCMHs. In Montana, PCMHs for state employees have saved $100 million over five years. And PCMHs have saved IBM s U.S. division $1.7 billion in health costs in the past eight years. A review of the evidence from prospective evaluation studies found that costs for patients in PCMHs dropped an average of 15.6%. That included decreases of 36.3% in hospital days and 32.2% in ER use. At the same time, utilization of medications for chronic diseases increased 12.8%. Ultimately, the PCMH alone is not enough to achieve the Triple Aim; physicians must want to get there. And to do that, they must be accountable for using data to manage population health effectively. So the first step in the journey is not to put technology or standards in place, but to ask physicians what they are willing to hold themselves accountable for. If you manage the population better upstream, you reduce the use of hospital beds for ambulatory-sensitive conditions. This is better quality care, and it costs less than today s healthcare does. 4
5 Presenter: Ashok Rai, MD, president and chief executive officer, Prevea Health Lessons Learned on Journey to Population Health Management and Employer Alignment Prevea Health, a 300-provider group in Green Bay, Wisconsin, has patient-centered medical homes (PCMHs) in 15 primary care sites that include 50 providers and two care managers who care for 29,000 patients. When Prevea launched its first PCMH in 2009, the group was trying to move away from episodic care and embrace population health management. Its care managers had to identify the sickest patients a difficult task, even with Prevea s electronic health record and support them with education, preventive care reminders, community resources, nutrition advice, and wellness opportunities. They also had to figure out how to overcome the resistance of some patients and increase their self-efficacy in managing their own care. Prevea received National Committee on Quality Assurance (NCQA) recognition for its medical homes, but the ability of those practices to manage population health hit a wall because their care management processes were largely manual. Automation was limited; registries were rudimentary. A time-and-motion study done at the time showed that care managers were spending an average of 188 minutes per patient, including 47.5 minutes on finding the necessary information in their electronic charts. As a result, each care manager was only able to manage an average of 2.5 patients a day. But today, with the aid of automation tools from Phytel that extract the latest, most relevant information from Prevea s EHR, care managers can each handle 6.5 patients daily, on average. Care managers now use risk stratification software to identify the patients who they know they must contact. In addition, providers now have a dashboard that shows them how various segments of their population are doing and how they are performing in relation to their peers. Prevea uses another application to alert patients who need preventive or chronic care to make an appointment with their providers. In a published study, Prevea showed that this tool helped increase patient compliance. And the group has designed online interventions for groups with low, medium, and high health risks as part of its population health management strategy. It also has a patient portal to increase patient engagement. Overall, Prevea s investment in PCMHs has paid off in terms of improved outcomes, while its outreach efforts have increased the percentage of patients receiving appropriate care. Prevea s investment in patient-centered medical homes has paid off in terms of improved outcomes, while its outreach efforts have increased the percentage of patients receiving appropriate care. 5
6 Presenter: Cliff Fullerton, MD, vice president, chronic disease and care redesign, Baylor Health, and chief quality officer, Health Texas Provider Network Achieving High Quality, Low Cost Care in a Changing Environment Dallas-based Baylor Health, which includes 30 hospitals and 194 ambulatory-care clinics with 600 employed doctors, has launched an all-out effort to redesign its primary care to prepare for the tsunami of healthcare reform. The foundation of this initiative is the patient-centered medical home (PCMH), and the keys to success include the use of technology tools and team care to do population health management. With its payer mix shifting away from commercial payers to Medicare, Medicaid, and self-pay, Baylor has decided it must reach break-even on its Medicare patients. Meanwhile, the system is expecting an additional 100,000 patients in early 2013, raising demand for its providers. And reimbursement models are changing: Baylor already has some shared-savings contracts and is in discussion with payers about bundled payments for joint replacements. Risk contracts are on the horizon. With all these changes in the wind, Baylor has adopted a clinical integration and care coordination strategy keyed to PCMHs. It already has 60 PCMH clinics with 280 physicians and 59 non-physician providers. Among the top challenges to Baylor s new primary care model are how to provide access to patients; meet the demand for quality data from public and private payers and other organizations; cope with physician stress; and address the need for better care coordination, which shifts how physicians work in a team environment. To manage these challenges, Baylor s primary care doctors are being transitioned to leaders of care teams that can care for twice as many patients as the doctors can individually, partly through the use of non-visit care, group visits, and visits to non-physician clinicians. CMAs are starting to take histories and become care coordinators for the 20% of the population that is chronically ill, while RN health coaches are working with the 5% of patients who are classified as high risk. Ten care coordinators support 54 clinics and 250 physicians. Each of them averages 71 patient contacts a day, 38% by phone. All patients are receiving automated reminders and education. Baylor is using a wide array of technology tools, half of them from outside vendors. These include applications for data aggregation, data analytics, data access (dashboard, patient portal, health information exchange), risk stratification, remote monitoring (for heart failure), an electronic health record, in-office kiosks, and automated outreach. The outcomes from Baylor s approach in its NCQAcertified medical homes have been impressive. Scores on five outcomes measures have increased from 53% to 70% of patients at goal, while the clinics have raised their percentage of patients receiving 11 preventive services from 76% to 87%. Bridges to Excellence has recognized 149 of 175 eligible Baylor doctors for excellence in diabetes care. Meanwhile, the clinics received $1.3 million in pay for performance bonuses this year and are expected to double that next year. 6 Baylor Health has launched an all-out effort to redesign its primary care to prepare for the tsunami of healthcare reform. The foundation of this initiative is the patient-centered medical home, and the keys to success include the use of technology tools and team care to do population health management.
7 Presenters: Sharon Lucie (on left), vice president of operations, and Lindsay Gainer (on right), RN, director of clinical services and innovation, North Shore Physicians Group Hard-Wiring the Primary Care Practice for Success in a Value-Based Environment North Shore Physicians Group, a 290-provider practice near Boston, is affiliated with North Shore Medical Center and is part of Partners Healthcare. Nearly four-fifths of its revenues come from risk contracts, including Partners Pioneer ACO contract with Medicare and alternative quality contracts from the top three commercial payers in the area. So cutting costs and improving quality are mission-critical goals for North Shore. As a first step, the physician group has transformed its 11 primary care sites into patient-centered medical homes. To redesign the workflow in these practices, North Shore studied and collaborated with Seattle s Virginia Mason Medical Center, which has perfected the application of Toyota s lean production model to healthcare. Among the key facets of North Shore s approach are open access scheduling, team care, a continuous flow approach in the office, standardized, evidence-based care, measurement of results, rapid cycle improvement, commitment to safety, and a systematic assessment of all patients care needs, whether or not they visit their providers. In addition, the primary care practices are so patient-focused that they have formed a patient family advisory council to help guide them. About 75% of the staff have received training in lean techniques ranging from continuous workflow to just-intime supply ordering. Medical assistants (MAs) have also received additional training so they can become more capable members of the care teams. The MAs like the additional training and their expanded role as flow managers. What this means is that the MA now controls access to the provider and handles a variety of tasks, including medication reviews, health maintenance reminders and some EHR data entry. The MAs may start notes for patients, taking down their chief complaints. Doctors can have better visits with patients as a result of not having to enter this data themselves. Physicians may also provide standing orders for MAs in areas like immunizations and EKG tests. The MAs save time for doctors in other ways, such as filling out forms for patients and having the providers sign them. And they are collocated in the same offices as providers, which reduces walking time and time spent on exchanging messages. There are two types of nurse care managers who manage Medicare patients and members of the three plans that delegate risk to North Shore. Populationbased care managers work with patients who are at moderate risk and need help with chronic disease management. Each of these nurses handles about 500 patients. High-risk care managers each take care of about 200 high-risk patients. Both kinds of care managers work closely with social workers, behavioral specialists, and community resource specialists imbedded in the practices. Physicians and their care teams continue to expand to achieve their primary care goals. Together, they can manage care for everyone in their patient population. The early proof of that has come in improved patient satisfaction and HEDIS quality scores. Physicians and their care teams continue to expand to achieve their primary care goals. Together, they can manage care for everyone in their patient population. 7
8 Panel members: Rick Warren (left), vice president and chief information officer, Allegiance Health; Allana Cummings (middle), chief information officer, Northeast Georgia Physicians Group; Renee Broadbent (right), chief information officer and information security officer, Accountable Care Associates, LLC Building Successful Clinical Integration Across the Continuum The health information exchanges (HIEs) needed for full clinical integration are still in an early stage of development, the panelists agreed. Right now, most providers are just trying to exchange minimum data sets to manage their patient populations, Cummings noted. In any given community, about two-thirds of the providers who have EHRs are willing to exchange data with each other, she observed. The challenge is to combine data from different patient registries to supply a full picture of patient care. Data warehouses can be used to aggregate and normalize the data and send actionable reports back to the providers, Broadbent said. The key to success, Cummings declared, is physician participation. To obtain that, she said, Find out what providers need, not what the regulations require. Her observation underlined the changing role of the chief information officer in healthcare organizations. Ten years ago, Cummings noted, most CIOs were IT directors. Now they need to be among the organization s decision makers and help drive business strategy. To earn a seat at the executive table, she said, CIOs must be able to do far more than implement technology. They must understand business operations and how to take data and turn it into actionable information for clinicians. They must show leadership and not be afraid to plunge into the clinical side when needed. Most of all, they must move from being integrators of data to being integrators of workflow. Warren agreed, noting that he has been on the executive council of Allegiance Health since In recent years, he said, he has progressively become less of a technologist and more of a strategist. He looks at where healthcare is going and figures out how to get the organization there. Broadbent noted that technology solutions do not always fit healthcare organizations work processes, so some of them try to customize those applications or build new ones. But Cummings said most organizations lack the resources to develop their own software. Even very large healthcare providers, she said, tend to buy off the shelf commercial solutions. However, she cautioned, organizations must be very careful in selecting third-party solutions. For example, there are lots of business intelligence tools on the market, but providers must find the right ones to meet their goals. Also, the solution must be affordable, because IT purchases can quickly add up to a large amount of money. Healthcare organizations are now devoting 4-6% of their capital investments to health IT, compared to 2-3% a few years ago, she pointed out. The message for healthcare systems that aim to achieve clinical integration and do population health management is clear: There are viable solutions on the market, but providers must choose the right ones to be successful and achieve a return on their investment. 8 The message for healthcare systems that aim to achieve clinical integration and do population health management is clear: There are viable solutions on the market, but providers must choose the right ones to be successful and achieve a return on their investment.
9 Presenter: Farzad Mostashari, MD, national coordinator of health information technology Applying Data Analytics to Manage Population Health Meaningful Use of electronic health record technology is not about moving patients in and out of a physician office more efficiently. It s about trying to prevent heart attacks and strokes and to manage the care of a patient population. It s totally do-able, and many healthcare providers are doing it already. When Mostashari was with the New York City Department of Hospitals and Mental Hygiene, he was interested, as an epidemiologist, in detecting public health patterns so that the department could intervene to improve health. Eventually, he recognized that physicians needed EHRs to collect the data required for this effort. So he persuaded the city to subsidize EHRs for doctors in poor neighborhoods. When he interviewed EHR vendors, he discovered that few of them offered applications for managing population health or robust clinical decision support. The department decided to work with one vendor to build the tools it needed, and the enhanced product was rolled out to hundreds of doctors in New York. Within the past two years, there has been a national shift in IT capabilities that enable healthcare providers to do population health management. Phytel s solutions and the conference attendees use of those products are a testament to how quickly this is changing. There are also now better tools to measure outcomes, and payment models are changing to encourage a more holistic approach to care. Data is the oxygen for innovation and better care, but it has to be visible, not trapped in silos or unstructured data. For example, registries are an important component of population health management. But to build a registry, data must be recorded in structured fields, not locked up in free text. No matter how difficult it is to collect data and change workflow, it s worth it. Because, without measuring the processes and results of care, providers can t improve what they do. Physicians are rightly concerned about the multiplicity of quality measures they have to report to a variety of payers and other parties. The Centers for Medicare and Medicaid Services has tried to address this issue by aligning its Meaningful Use Stage 2 measures with those in its PQRS and ACO shared savings programs. Commercial payers are a ways away from agreeing on a set of standard measures. Data is the oxygen for innovation and better care, but it has to be visible, not trapped in silos or unstructured data. 9
10 Presenters: Ray King, MD, senior vice president and chief medical officer, Allegiance Health; Wynn Hazen, chief operating officer, Jackson Health Network Accelerating Health Care Transformation The key to successful population health management is getting patients to change their health behavior. Healthcare affects no more than 10% to 15% of population health; the rest is the product of environment, genetic factors, and patients willingness to take care of themselves. With this in mind, Allegiance Health, the sole hospital in Jackson, Michigan, combined forces with community physicians, the United Way, the county health department, and other agencies to form a community coordinating council aimed at improving the health of Jackson residents. A community health assessment performed in 2006 showed that 70% of county residents were overweight or obese, 27% smoked, 75% didn t get enough exercise, and most people didn t eat enough fruits and vegetables. The council set long-range goals to change those trends. Meanwhile, local business leaders had launched an initiative to improve the health of their employees. With the help of area providers, they sponsored health risk assessments, personal coaching, targeted health education, enhanced preventive services, and other types of support. The results have been impressive: from 2002 to 2011, the percentage of participants with low health risks climbed from 50% to 68%. The medium-risk category dropped from 30% to 23% of participants, and the percentage of those at high risk fell from 20% to 9%. During this period, healthcare providers also realized they needed a better way to improve community health with the aid of health IT. In 2005, Allegiance Health and the local physician organization launched the Jackson Community Medical Record (JCMR). More than 150 doctors including employed and independent physicians and the county health department now use the same EHR and can easily exchange patient data. Recently, the hospital and physicians formed a clinically integrated structure, the Jackson Health Network (JHN), to achieve the Triple Aim of the Institute for Healthcare Improvement. Nearly 80% of area physicians 218 doctors in 28 specialties are participating in JHN. The network is doing a beta test with one employer and is in discussions for two commercial insurance contracts in JHN has added a web-based registry and has begun using a Phytel solution to do internal quality reporting. Physicians can use the quality feedback to compare their performance with that of their peers and find out which patients aren t getting the care they need. In 2013, JHN will get specialists more involved in clinical integration. It will also pilot care management programs and expand workflow redesign. 10 The key to successful population health management is getting patients to change their health behavior. Healthcare affects no more than 10% to 15% of population health; the rest is the product of environment, genetic factors, and patients willingness to take care of themselves.
11 Presenter: Donald Lurye, MD, chief executive officer, Elmhurst Clinic Before You Click Creating an Information-Centered Culture Traditional physician culture is based on the autonomy of the individual practitioner. But that culture must change to one grounded in information and evidence to improve the quality of care. Informational culture converts data into actionable information, which tells an organization how to redesign care and measure performance. It also minimizes variation, which is the enemy of quality, without turning patients into widgets. To achieve an information-centered culture, a healthcare organization needs strong physician leadership. There must also be a compact between the doctors and the organization on what each expects of the other. And there must be an orderly process for group decisions. Once a practice grows to more than about eight physicians, decisions should be delegated to a steering committee structure to facilitate effective decision-making. The goal of centralized decision-making is to standardize major workflows. Physician groups must learn how to practice together rather than alone within the group. The practice leaders must be able to make some decisions unilaterally, guided by the compact between the physicians and the organization. The Elmhurst Clinic, a Chicago-area group, made this work in the area of refill management. Elmhurst, which includes about 100 providers, received 120,000 refill requests per year. Every request was handled differently, in accordance with each physician s wishes. Having multiple staff members interpret each doctor s style led to chaos and inefficiency. There was an obvious need to standardize the process. Elmhurst decided to adopt the refill protocols developed by Lyle Berkowitz at Northwestern Memorial Hospital in Chicago. Nurses were empowered to follow these protocols for common refills, saving doctors time and giving patients a quicker response. The group recently introduced standing orders for certain lab orders and mammograms, using protocols for nurse case managers. If a patient with a chronic illness needs such a test, a nurse can order it without consulting a doctor. Meanwhile, Elmhurst is moving forward rapidly on population health management, which will also require culture change and physician buy-in. It has been using Phytel solutions for the past few years and is now implementing a new solution in which care managers will use data to help fill patient care gaps. Using these tools, the practice will reach its silent patients and decrease their care gaps over time. Informational culture converts data into actionable information, which tells an organization how to redesign care and measure performance. It also minimizes variation, which is the enemy of quality, without turning patients into widgets. 11
12 Presenters: Richard Hodach (left), MD, chief medical officer, and Russell Olsen (right), vice president, product management, Phytel Day in the Life of a CMO: Managing a Contract for Diabetes Imagine you re the CMO of a multispecialty group with 50 providers, half of them primary care doctors. Your practice has 250,000 patients and a business that s 70% commercial insurance. The group received NCQA recognition in 2011 for its patient-centered medical homes (PCMHs), and it s considering some risk-based contracts. A health plan with 100,000 patients wants the group to sign a quality-based contract to manage patients with diabetes. The main goal is to decrease the number of patients who have high A1C values. If the practice can do that, it will get a bonus. To reach this goal, the group first needs a high-level overview of the diabetic patients who are insured by this health plan. Based on the prevalence of diabetes in the population, there are about 8,000 patients in that category. Currently, only 38% of them are in full compliance with their care plans, and a significant percentage of these patients have an A1C >9. The group has an application sitting on top of its EHR that can identify the patients with diabetes and attribute them to their primary providers. It also extracts the baseline A1C and blood pressure values for this population. Now you can see how individual providers are doing and how they could improve. Using this data, you can sit down with the providers, explain what the contract is about, and give them data on their performance. Next, you can share your findings with the group s quality committee, which sets goals e.g., see all diabetics twice yearly and decrease their average A1C by one percent within a year. Then the committee decides how the group is going to get there with the help of automation tools that can: + Risk stratify the population + Segment the population by condition, insurance, etc. + Identify care gaps + Alert patients who have care gaps that they need to make appointments + Help care managers identify high-risk patients who they need to focus on + Enable care managers to initiate a variety of micro-campaigns for all patients with diabetes + Help providers do pre-visit preparation + Survey patients to improve post-discharge care and ensure that the patients get their questions answered + Generate performance reports for physician feedback, showing doctors how they compare with their peers and national benchmarks Automation tools like these can facilitate most aspects of population health management. In addition, providers that use Phytel solutions can get auto-credit toward NCQA recognition of their PCMHs. Automation tools like these can facilitate most aspects of population health management. In addition, providers that use Phytel solutions can get auto-credit toward NCQA recognition of their patient-centered medical homes. 12