The Science of Healthcare Delivery: A Glimpse Into the Future

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1 Dartmouth College MHCDS Tulsa Team The Science of Healthcare Delivery: A Glimpse Into the Future David Adelson, MD, MS Jeffrey Alderman, MD, MS

2 Beginnings The problems of health care throughout the world are not primarily ones of medical knowledge or even political will they are problems of effective management and execution. -Jim Yong Kim, 17 th President of Dartmouth College

3 Defining Health Health is a state of complete physical, mental, and social wellbeing It is not the mere absence of disease or infirmity World Health Organization

4 Determinants of Health Income and Social Status Education Physical Environment Employment and Working Conditions Social Support Culture, Customs and Traditions Genetics Personal Behavior/Coping Medical Care World Health Organization

5 Centers for Disease Control, Social Determinants of Health

6 Assumptions With advances in technology, we are living longer, but with a greater burden of disease The share of people living with poorer health is rising 45,000 preventable deaths are associated with lack of health insurance annually equivalent of 1 Boeing 737 jet crashing every day. -American Journal of Public Health, Harvard University School of Public Health

7 Unwarranted Variation

8 Wages & Inflation have not kept pace with Health Care Spending

9 Are We Wasting Resources? 20 to 30 percent of health spending is waste that yields no benefit to patients. - Don Berwick, M.D. 12/3/11

10 End Results from Our Current Delivery System Poor health and high healthcare spending are primary threats to the American economy and our way of life. Medical Debt is the greatest source of personal (and corporate) bankruptcy Variation is widespread, raising costs and reducing quality Himmelstein, et al. Health Affairs, Feb 2005

11 Building a Better Healthcare System Creating Value Requires a Three Prong Approach Higher Quality Healthcare TRIPLE AIM Better Experience of Care Decreased Costs of Care

12 Paying for Population Health Management Shifting away from payment models that reward reactive care towards ones that promote proactive and preventive care Paying for Value: Better outcomes at lower costs What is the system s cost and quality performance across the entire patient experience? From primary to specialist care From prescription drug to diagnostic service utilization From acute to post acute care

13 Strategically Strategy Changing for Change Healthcare

14 Seeking Value in Healthcare Value = Quality + Satisfaction Cost Michael Porter & Elizabeth Tiesberg, 2010

15 Seeking Value in Healthcare Value = Quality + Satisfaction Cost More than just lowering costs More than just adding/subtracting care Raising the quality of care Offering it to as many people as possible Affordable prices Welcoming environment Promotes the development of positive self-care behaviors Michael Porter & Elizabeth Tiesberg, 2010

16 Seeking Value in Healthcare Value based competition will drive the improvement of the healthcare system Organize Integrated Practice Units across facilities, around patient medical conditions Measure outcomes and costs for every patient

17 Seeking Value in Healthcare Payments should be bundled across the entire cycle of care Care must be scalable, and integrated across multiple facilities Expand successful practice units across geographical regions

18 Creating the Future of Health Delivery

19 Payment Reform Move away from fee-for-service toward new methods of reimbursement Align provider incentives to outcomes Examples: Bundled payments Global Capitation Accountable care organizations Pay for performance

20 Rethinking Cost-Sharing Responsibilities One Size does not Fit All Deductibles & co-payments decreases use of all types of services People avoid essential AND non- essential care But if there is NO cost-sharing, people use more of both necessary AND unnecessary care People s incomes matter Cost-sharing hits sicker and lower income people harder Encourages avoidance of all care

21 Aligning Patient Incentives Smart cost-sharing Does not discourage important, essential care annual check-ups, immunizations Does not discourage use of necessary medications Encourages appropriate consideration of pros and cons of potentially unnecessary procedures that do not have proven benefit and can be wasteful to the system

22 Bundled Payments

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24 ACO s: There will be Blood! ACO/CPCI Incentive to Deliver Quality Care Capitation Fee for Service Incentive to Limit Care Incentive to Overtreat

25 Accountable Care Organizations New provider organizational structure Medicaid & Medicare authority Provider takes on insurance risk Shared savings between payer & provider Capitated reimbursements from payer to ACO Savings is split among providers within ACO

26 Recalculating True Costs TDABC time driven activity based costing Method created by Robert Kaplan & Michael Porter New approach that measures cost as patient level for a given condition over a full cycle of care and compares those costs to outcomes As providers & payers better understand costs, they will be positioned to achieve a true bending of the cost curve

27 Shared Decision Making Collaboration between patients and caregivers to come to an agreement about a health care decision. The Provider Helps Patients: Understand the likely outcomes of various options Think about what is personally important about the risks and benefits of each option Participate in decisions about medical care

28 Reengineering Chronic Disease Management Studies have shown that Chronic Disease Management Programs (CDMP) can reduce the incidence, complications and cost from many illnesses (CHF, DM, Asthma) Robust CDMP s prevent avoidable ED visits, increase life-satisfaction, prevent the need for invasive surgeries, and improve mortality 1. Cohen, J.T., P.J. Neumann, and M.C. Weinstein, N Engl J Med, (7): p Villagra, V.G. and T. Ahmed, Health Aff (Millwood), (4): p

29 Reengineering Disease Management

30 Care Coordination Care coordination is an approach to health care in which patient's needs are coordinated with the assistance of a Care Manager The Care Manager provides information to the patient and the patient's caregivers, and works with the patient to make sure that the patient gets the most appropriate treatment.

31 Care Coordination Reduces unnecessary duplication, testing and acutecare utilization. This process saves money on health care costs and improves the quality of care.

32 Jeff Brenner & Hot Spotting In Camden, New Jersey, one per cent of patients account for a third of the city s medical costs

33 Jeff Brenner & Hot Spotting Camden, NJ - Non-urgent use of Emergency room by census tract

34 Create Robust Health Information Technology

35 Wide Scale use of Palliative Care

36 Iora Disrupting the Patient Centered Medical Home Comprehensive primary health care for a fixed per member per month fee.

37 Shared Savings Infrastructure e.g. Comprehensive Primary Care Initiative Medical Informatics and Health Information Exchange Development e.g. Beacon Communities Grant, Pentaho for Population Health Management THE NEW MODEL FOR CARE AND EDUCATION Health Workforce Development e.g. Summer Institute, Teaching Health Center, Residency Program, Physician Assistant Medical Student and Resident Physician Training Expansion and full immersion in new models of team / medical home care, training expansion grant Patient Centered Medical Homes Medicare, Oklahoma Medicaid, Blue Cross contracts, Bedlam student led clinics, PAL PCMH at Morton Clinic Care Coordination - e.g. Health Access Network Program with Oklahoma Medicaid 70,000 patients Vulnerable Populations e.g. Child Abuse Team HARUV, IMPACT Team for Mental Illness, Palliative Care team for chronic illness, Heart Intervention Program for MI and Stroke Prevention

38 Patient Reported Outcomes

39 NIH PROMIS Click to edit Master title style

40 Vision-Mission: Vision The Patient-Reported Outcomes Measurement Information System (PROMIS ), funded by the National Institutes of Health, aims to provide clinicians and researchers access to efficient, precise, valid, and responsive adult- and childreported measures of health. Click to edit Master title style Mission PROMIS uses measurement science to create an efficient state-of-the-art assessment system for self-reported health.

41 The Tower of Babel (Brueghel, 1563)

42 Evolving concept of health DOMAIN vs. Click to edit Master title style DISEASE SPECIFIC

43 DOMAINS A domain is the specific feeling, function, or perception you want to measure. Click to edit Master title style Cuts across different diseases

44 Domains & Diseases: Hypotheses Diseases are combinations of different domains fatigue, physical function, anxiety, pain Capturing multiple domains may be optimal Click to way edit to Master assess title diseases style Core-common PRO domains are universally applicable across diseases (common or rare), ages and ethnicities

45 Mechanisms PROs Interleukins Chemokines Phys Fn Social Fatigue Sleep Anxiety Pain Prostaglandins

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47 The Future of Healthcare in Tulsa Team Based Care and Care Coordination (no longer just one doctor, one patient and one room) Leveraging HIT to care for Patient Populations ACA more people (but not everyone) insured Standardization of Care to Reduce Variation Health Systems Measured by (and competing) on Quality

48 The Future of Healthcare in Tulsa Innovations that incorporate all three arms of the Triple Aim Shared Decision-Making New Payment Systems: Less Fee-for-Service, more Risk-Based Contracting Increased scrutiny of care delivered close to the Endof-Life, with more emphasis on Share Patient, Family, and Provider Goals and Values

49 The Future of Healthcare in Tulsa Doctor Leads (but may not coordinate) a Team of Health Care Professionals Acute Sensitivity to the Cost of Care Sensitivity to Disparate Populations More Loan payback through Service Scholarships More Headaches!