Use Facility Image if available How to Select the Right Pop Health Vendor for Your Organization

Transcription

1 Use Facility Image if available How to Select the Right Pop Health Vendor for Your Organization May 19, 2016

2 Agenda I. Case Study: Illinois Partnership for Heath (IPH) II. Population Health Management (PHM) and PHM Technology II. The PHM Technology Market III. IPH Approach IV. Lessons Learned V. Questions 1

3 Illinois Medicaid Reform Law The starting point Illinois Medicaid Reform Legislation required 50% of clients to be enrolled in an MCO by 2015, for some counties the percentage was to be 100%. At the end of 2013, 3.1 million individuals were enrolled in Illinois Medicaid, including 400,000 enrollees from the Affordable Care Act (ACA) Medicaid expansion. For 2014, Medicaid accounted for 26% of the total state budget. The state offered an opportunity for a new option an Accountable Care Entity (ACE) to be formed by provider organizations to be an alternative to existing insurance plan managed care organizations. 2

4 ACE Program» Definition The ACE program is modeled after the federal government s CMS ACO initiative. Provider based An integrated delivery system Capacity to securely pass clinical information across its provider network The ability to aggregate/analyze data to coordinate care. It must be a model of care and a financial management structure that promotes provider accountability, quality improvement, and enhanced health outcomes.» Population The ACE serves the Family Health Plan population and new ACA adults who are eligible for Medicaid.» Solicitation HFS issued a solicitation in September 2013 for organizations to become an ACE. 26 letters of intent were submitted 8 ACE s actually became operational 3

5 Case Study: Illinois Partnership for Health Organizational Formation: The Founders Nine health systems, their employed and affiliated providers, and an experienced payer (Health Alliance Medical Plan or HAMP) joined together in a collaborative effort to form the IPH, also known as the Super ACE of Illinois. ACE Service Area The network of the original nine founder organizations represented:» 64 of the 102 counties of Illinois.» The capacity to serve 126,000 enrollees.» More than 8,000 individual providers.» 63 inpatient acute care facilities. Blessing Health System Cadence Health Centegra Health System Decatur Memorial Hospital KishHealth System Lurie Children's Hospital McDonough District Hospital Memorial Health System OSF HealthCare Riverside HealthCare Rockford Health System The Carle Foundation ACE Service Area in Mandatory Enrollment Region ACE Service Area in Voluntary Enrollment Region Not Within ACE Service Area 4

6 Case Study: Illinois Partnership for Health The IPH ACE Program» ACE Contract HFS awarded IPH an ACE contract in February 2014.» Enrollment ACE enrollment began in mid-july 2014 and was geographically phased in across the State. IPH enrolled 20,000 plus members some months, with a peak enrollment of ~120,000.» Mixed Responsibilities For the initial period, the state would still: Manage enrollment, assign provider assignment, disenrollment. Pay fee-for-service at Medicaid rates State would pay a PMPM care coordination fee.» Future State After the first 18 months of operation, the IPH would transition to a MCO, accepting full risk for the total cost of care. 5

7 PHM and PHM Technology PHM Defined THE P O P U L A T I O N H E A L T H M A N D A T E PHM is a patientoriented care delivery strategy executed by providers that are financially accountable for meeting the goals of the Triple Aim for a defined patient population. Shared Savings Capitation Care Management Per Member Per Month (PPM) Fees Improve Patient Experience While technology alone will not accomplish population health or integrated care, it enables almost all elements of a PHM program. Improve Health Reduce Per Capita Cost 6

8 Key Facts for IPH 1. A Medicaid population state enrollment registries 2. A promise of two years of claims data when available 3. Tens of thousands new enrollees per month 4. Contract requirements deadlines for: - Initial contact - Patient risk assignment - Care coordination defined ratios and deadlines - Initial fee-for-service (state receives bills and pays) - Financial risk - HEDIS and other quality measures - EBM protocols for 18 conditions 7

9 Technologies Supporting PHM PHM combines technological functionality from the use of electronic health records (EHRs), data integration or exchange, care management, and analytics. EHRs are foundational to capturing data related to the patient record and are the sole tool that can provide clinicians with decision support and guidance on management protocols at the point of care. Care Management EHRs Aggregated Data Integrating Systems Data is collected from claims, EHR systems, and other sources to support required reporting (e.g., quality metrics required by contract) or internal monitoring of performance, cost, clinical outcomes, and many other elements. IT systems also support the activity of care managers, helping to identify patients who need specific interventions and facilitating patient communication. Reporting and Analytics Integration tools (HIEs and other data integrators) help providers exchange information on shared patients to create comprehensive patient views and facilitate transitions of care. Understanding capabilities in these areas will provide you with insight into the technology you currently have to support PHM. 8

10 The PHM Technology Market The PHM technology market is very dynamic, and the vendors are difficult to compare.» There are over 180 vendors in the PHM technology market. The KLAS classifications do not organize these vendors by their unique functions very well.» The market is very dynamic and includes a lot of entry and exit,.» Many vendors evolved from an offering in one area, such as HIE, which remains their strength.» It is difficult to compare any two PHM technology vendors, as they can offer any combination of the functional categories below. Data Integration and Exchange Ability to support data exchange between providers or combine clinical and claims data in a way that creates a true longitudinal record Performance Analytics Clinical, financial, and quality analytics to support a variety of measures Care Management Functionality to support the work of care managers Know your needs! It is very common to overor under-purchase technology in this market because of shifting definitions and disparity in functional offerings. 9

11 The PHM Technology Market Apples and Oranges PHM technology solutions offer a variety of combinations of functions to meet healthcare organizations various needs. Disease Registries Care Patient Management Vendor 2: Engagement Work Flow Support Risk Stratification Focuses on Care Management Vendor 3: Focuses on Performance Improvement Clinical Outcomes Measurement Quality Performance Reporting Transitions of Care Support Clinical Information Exchange 10

12 IPH Questions to Address Where will data come from? 1. Local, state, national information? 2. What about practices without EMR s? 3. How do you connect with agencies providing services (health dept., mental health services, etc.) 4. Do you want/need unstructured as well as structured data? 5. Do you have existing data connectivity, integration, analytics, security, registries? Where do you have gaps? 11

13 IPH Information Technology Approach Through a representative IT committee including joint meetings with clinicians, IPH sought to determine individual Founder current capacities as well as Founder gaps and collective central organizational requirements needed to determine and manage: 1. Patient risk 2. Care Coordination 3. Efficiency/ Cost of Care 4. Transitions of Care 5. Quality of Care 6. Network and Provider Profiling 12

14 Score Priority Score Priority Comparing Vendors to Your Needs Founder/Vendor Data security Data silos Data acquisition timing Data Reporting timing Data Exportable Data Normalization Big data platform Scalability Integration to HIE/ HIE platform Proven Connectivity Patient Registry/identification Custom Reporting Standard Reports Company stability Client List/Experience Base Cost Care Coordination program Alerts / reminders Best Practices - value driven Risk assessment Provider Attribution Total cost of care 13

15 Consensus and Decision Vendor Comparison Product A starting point, not the final decision A B C D Minimum acceptable score per Founder? Founder St. Elsewhere Equal weighting? Hope Hospital A basis to start discussions Memorial Negotiation Tactics MyLutheran Charity Overall Mean S.D

16 Population Health Maturity Case Study: IPH IPH initiated operations using a centralized risk scoring system, local founder EHRs and care management systems, and local analytics. The long-term vision involved moving to a broad-based PHM platform to integrate data across the network as the organization moved to full risk. Organizational Foundation Provider Network Payment Models Care Models Technology Highly Evolved (PHM 301) Formal and active PHM structure with specific (FTE) PHM leadership Fully contracted network, direct to employer Capitation, payor collaboration Coordination across all patient populations Longitudinal record of care; centralized value analytics Transitional (PHM 201) Organization engaged in opportunities in PHM and willing to make investments Inclusion of specialists and contractors; performance requirements Upside/ downside risk bundles Coordination across larger patient populations Enterprise EHR (IP/OP); risk scoring; some data integration, care management functionality Developing (PHM 101) Existing but not prolific PHM structure Open network, PCP-driven P4P, upside-only shared savings, PMPM Coordination across certain conditions or service lines Deployed EHR; claims-based analytics, HIE utilization No Development No quality committees, no defined business strategies for PHM No provider alignment FFS No integration or care coordination Substantial paperbased and manual reporting; EHRbased tools 15

17 Case Study: IPH The evolution of IPH over time meant that the IT strategy and infrastructure should be designed to evolve as the Founders assumed greater risk. Short-Term IT Strategy» Risk stratification using HAMP s central use of Risk Manager, a claims-based analytics system» Additional risk stratification locally using EHR data analytics to identify high-risk pregnancies and high utilizers» Local care management technology solutions, mostly using EHRs, to document HRAs and care plans» Each Founder committed to regional HIE utilization with a minimum level of secure messaging» Transitions of care between IP and OP within individual Founder EHR solutions» Quality and performance reporting completed by HAMP centrally on an annual basis (HEDIS, etc.) Long-Term IT Strategy» Continue to optimize use of EHRs for care management functionality.» Invest in integrating software (Explorys ) to allow for greater functionality to be centralized and normalized across Founders. More accurate and timely risk stratification Ability to monitor performance metrics centrally by IPH staff Longitudinal care record to show if members were seeking care outside of individual Founder systems More frequent ability to monitor quality and care gap analytics More robust analytics to create clinical cohorts and support clinical campaigns Big data platform 16

18 Lessons Learned Considering the development of an ACO or similar value-based delivery model but uncertain about when to make big investments in PHM technology? Build the Right Internal Team Understand the Contract and Expectations Understand Your Needs Stage and Scale Integrate, Consolidate - Be Strategic Seek Flexible Solutions that will not easily outdate It takes an integrated, connected village If You Know It All, Great, Otherwise Get Help Start Early Start Now Managed Care = E 2 17

19 Questions & Discussion Michael Zia, M.D. Developing a flexible and realistic approach and model will further ensure success in today s value-based environment. 18