Meeting Increasing Needs by Redesigning Care Delivery & Controlling Costs Timothy Ferris, MD, MPH Vice President for Population Health Management, Partners HealthCare Medical Director, Mass General Physicians Organization World Congress on Integrated Care November 8, 2013
2 Rising health care costs have squeezed employers and employees for years 200% 180% Cumulative Increases in National Health Care Premiums, Workers Contributions to Premiums, Inflation, and Workers Earnings, 1999-2012 180% 160% 140% Health Insurance Premiums Workers' Contribution to Premiums 172% 120% Workers' Earnings 113% 100% Overall Inflation 109% 80% 60% 40% 20% 38% 11% 38% 29% 24% 47% 38% 0% 8% 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2012.).
What we re facing Constraining the growth of healthcare costs is a national priority Involvement of physicians through changed incentives is unavoidable PPACA - the imperative will persist even if the specifics change The market is using a similar play book closed networks, budgetbased risk, cost sharing, restriction of choice and this may generate the same backlash as 1990s managed care era But... The economy is much worse Government is proactive (3.6%) Rate of change is slower (caps on increases, not cuts) And we have Better health IT and data for population management Strategies and tactics that we know will improve care and reduce costs 3
Implications for providers The focus should be on reducing medical expense trend to as close to the rate of general inflation as we can This means taking financial risk for costs of care Shared savings (Pioneer ACO) Bundled payments Global payments Challenges 1. We need tactics that will be successful under any of the new payment models 2. How to make external incentives meaningful to our physicians 3. Moving at the right pace Too fast: we will lose the docs in the rush to implement MDs attitude often creates the patient's attitude (managed care backlash) Too slow: will mean not succeeding under the contracts and worsening the regulatory environment 4
Why Partners is aggressively pursuing global payment/population management Leadership opportunity to bend cost curve Efforts to reduce health care spending not going away Government being proactive Lesser of two evils Continued fee-for-service with endless rate cuts Global payments care redesign decreased utilization shared savings Partners increased ability to care for populations of patients Successful CMS Demo Universally adopted EHR 5
The path we re traveling at Partners Pressure to reduce cost trend New contracts with risk for trend Changes to Partners org structure Investment in Population Management Infrastructure Internal Performance Framework Network Affiliations 1 2 Partners in Care (PCMH & care coordination for high risk patients) Enhanced access to specialty services 3 Implement new local incentives/compensation 4 New relationships with community hospitals and doctors Sustained cost trends near GDP 6
7 One year in. Lives under the Accountable Care Model 1 2 3 4 Medicare Commercial Medicaid Self Insured Pioneer Accountable Care Organization Alternative Quality Contract (AQC) NHP Partners Plus Elderly population, care management central to trend management Younger population, specialists critical to management Population with significant disability, mental health, and substance abuse challenges Commercial population, but savings accrue directly to Partners, and improves our own lives Covered lives: ~65k Covered lives: ~350K Covered lives: ~25K Covered lives: ~80k Partners currently manages roughly 500,000 lives in various accountable care relationships
3 phases of work for improving population health Phase 2 Phase 3 Phase 1 1 Primary care: The hub for managing populations: preventive services, chronic illness, high risk 2 3 Specialty care: Where a large fraction of costs are incurred, especially in commercial populations Patient engagement: Involving patients in better self-management of care 4 Wellness Promotion: Programs to prevent or delay the progression of illness Ongoing: IS, analytics and central infrastructure 8
Matching care models to specific population needs ~43% of medicare spending 12 or more conditions ~14% of medicare spending 4 or more conditions 5% High-Risk 20% Rising-Risk High Risk Care Coordination + PCMH/Enhanced Primary Care ~8% of medicare spending 0 or 1 condition 75% Low Risk + Patient Portal, Social Media Outreach
Complex care management Care managers embedded in primary care practices Coordinate the care of patients at risk for poor outcomes, hospitalizations Supported by health IT (universal EHR, patient tracking, home monitoring) Adoption rapid and near universal among provider groups who are taking on financial risk populations MGH experience: CMS Demonstration, phase 1 Expansion, Phase 2 Pioneer ACO Patients MDs 2006 2,619 180 2009 6,530 336 2012 10,998 980 Ferris TG, et al; Cost Savings from Managing High-Risk Patients in The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary. Washington (DC): National Academies Press (US); 2010. 9, Care Culture and System Redesign. Available from: http://www.ncbi.nlm.nih.gov/books/nbk53910. 10
Medicare Demonstration Care team Healthcare & Community Services Non Acute Hospice VNAs Community Agencies Palliative Care and Hospice Community Resource Specialist Care Agencies Complex Care Team Substance Abuse Specialist PCP Care Manager Specialist Pharmacist Mental Health Team Financial Service Specialist Elder Service Network Transport Providers Civic Organizations 11
Medicare Demonstration Results Patient Outcomes Hospitalization rate: 20% lower ED visit rate: 25% lower Mortality rate: 4% lower Savings 7.1% net savings (12.1% gross) Approximately 4% annual savings for the total population For every $1 spent, the program saved at least $2.65 Cohort Gross Savings % Net Savings % MGH (1) 10.4% 5.9% MGH (2) 19.8% 15.1% BWH 7.0% 2.9% NSMC 4.1% -0.7% Average 11.83% 7.28% Source: Lessons from Medicare s Demonstration Projects on Disease Management and Care Coordination, Lyle Nelson, Congressional Budget Office, January 2012, Working Paper 2012-01 RTI evaluation http://www.massgeneral.org/news/assets/pdf/fullftireport.pdf 12
Evidence based care improvement tactics Longitudinal Care Episodic Care Primary Care Specialty Care Hospital Care Patient portal/physician portal Access program Access to care Extended hours/same day appointments Expand virtual visit options Reduced low acuity admissions Defined process standards in priority conditions (multidisciplinary teams) Design of care Measurement High risk care management 100% preventive services Shared decision making Appropriateness Chronic condition management Costs/population EHR with decision support and order entry Variance reporting/performance dashboards Quality metrics: clinical outcomes, satisfaction Incentive programs Costs/episode Re-admissions Hospital Acquired Conditions Hand-off and continuity programs Milford, CE, Ferris TG (2012 Aug). A modified golden rule for health care organizations. Mayo Clin Proc. 87(8):717-720. 13
MGH virtual visits and technology tools Technology Email MGH Pilots Primary Care Provider reviews patient s pre-visit questionnaire to determine treatment options and assess the need for visit or phone appointment. Videoconferencing Telephone Psychiatrist conducts a follow-up visit with an adolescent patient with autism for medication management. Cardiologist calls stable CAD patient to check-in on medications and symptoms between annual visits. Text Messaging Primary Care physician is alerted of alarm symptom in a patient who is completing an asynchronous virtual visit via web portal. Electronic Curbside Specialist reviews referral requests and triages to curbside consult answers PCP questions by email. 14
Evidence based care improvement tactics Longitudinal Care Episodic Care Primary Care Specialty Care Hospital Care Patient portal/physician portal Access program Access to care Extended hours/same day appointments Expand virtual visit options Reduced low acuity admissions Defined process standards in priority conditions (multidisciplinary teams) Design of care Measurement High risk care management 100% preventive services Shared decision making Appropriateness Chronic condition management Costs/population EHR with decision support and order entry Variance reporting/performance dashboards Quality metrics: clinical outcomes, satisfaction Incentive programs Costs/episode Re-admissions Hospital Acquired Conditions Hand-off and continuity programs Milford, CE, Ferris TG (2012 Aug). A modified golden rule for health care organizations. Mayo Clin Proc. 87(8):717-720. 15
Idealized patient journey through an episode of care that includes a procedure Patient Problem Assess Appropriateness Criteria Assess Risk Shared Personalized Decision Consent Making Form Tier 1, 2 Outcome Measures Tier 3 Outcome Measures Physician encounter Possible Need for Procedure Schedule Informed OR Consent Pre- Procedure Testing Procedure Recovery Outcome measures hierarchy: Tier Category Examples 1 Health status achieved Survival and degree of health recovery 2 Process of recovery Time to recovery and return to normal activities 3 Sustainability of health Sustained recovery and recurrences, including long term consequences of therapy 16
PrOE: inputs and outputs INPUTS PrOE Appropriateness tool OUTPUTS Procedure Scheduling Prepopulated data fields (NLP search) Appropriateness Indications & Decision support Internal Performance Dashboards LMR, OnCall RPM, RPDR, CDR, EMPI EMR EHR note created Data storage Copy of appropriateness results placed in LMR and CDR Appropriateness Data Repository Public Reporting Billing and Prior Authorization PCI, CABG, Vascular, Harris Joint Existing registries Data passback to registries (Web service) Measurement & analysis of appropriateness and outcomes inform guidelines and indications in real-time Personalized consent form 17
PrOE Procedure Decision Support Scale: 18
Evidence based care improvement tactics Longitudinal Care Episodic Care Primary Care Specialty Care Hospital Care Patient portal/physician portal Access program Access to care Extended hours/same day appointments Expand virtual visit options Reduced low acuity admissions Defined process standards in priority conditions (multidisciplinary teams) Design of care Measurement High risk care management 100% preventive services Shared decision making Appropriateness Chronic condition management Costs/population EHR with decision support and order entry Variance reporting/performance dashboards Quality metrics: clinical outcomes, satisfaction Incentive programs Costs/episode Re-admissions Hospital Acquired Conditions Hand-off and continuity programs Milford, CE, Ferris TG (2012 Aug). A modified golden rule for health care organizations. Mayo Clin Proc. 87(8):717-720. 19
Variation in use of high cost imaging Practice [N=11942] Dr. S [N=347] Dr. R [N=930] Dr. P [N=661] Dr. N [N=460] Dr. M [N=528] Dr. L [N=2101] Dr. K [N=1071] Dr. J [N=217] Dr. H [N=1304] Dr. G [N=538] Dr. F [N=963] Dr. E [N=839] Dr. D [N=409] Dr. C [N=397] Dr. B [N=700] Dr. A [N=460] 0.0 0.5 1.0 1.5 2.0 2.5 Providers Observed / Expected Ordered by: = Patient s PCP =Specialists =95% CI 20
Images / 100 Patients Utilization and variation both decreased from 06-09 40 Adjusted Images / 100 Patients By Doctor (N=137) 30 20 2006 practice mean = 16.1 standard error = 0.74 10 2009 practice mean = 12.1 standard error = 0.54 0 Doctors sorted by low to high (left-right) in each year 21
Evidence based care improvement tactics Longitudinal Care Episodic Care Primary Care Specialty Care Hospital Care Patient portal/physician portal Access program Access to care Extended hours/same day appointments Expand virtual visit options Reduced low acuity admissions Defined process standards in priority conditions (multidisciplinary teams) Design of care Measurement High risk care management 100% preventive services Shared decision making Appropriateness Chronic condition management Costs/population EHR with decision support and order entry Variance reporting/performance dashboards Quality metrics: clinical outcomes, satisfaction Incentive programs Costs/episode Re-admissions Hospital Acquired Conditions Hand-off and continuity programs Milford, CE, Ferris TG (2012 Aug). A modified golden rule for health care organizations. Mayo Clin Proc. 87(8):717-720. 22
Quality Incentive Program 1,700 eligible physicians Clinically active, non-trainees In at least 2 major managed care contracts Grouped into 3 RVU-based tiers Includes hospital-based and MGPO MDs Incentive payments total $6.5 million/year (~1.5% NPSR) Started with a bonus check in December 2006 Since then, 2 terms, 2 incentive payments per year (July & December) Max of $5,000 per MD per year Plan to pay out ~80% of funds each term 3 quality measures per term 2 are system measures & apply to all docs 1 is chosen by the clinical department in consultation with the QI Program Measurement can be individual, practice group, department or hospital-wide ~140 different measures have been used to date Eligibility Distribution Tier 1 ($500) Tier 2 ($1250) Tier 3 ($2500) 50-250 250-750 750+ RVUs over 6 months 23
MGH QI incentive system measures 2007 2008 2009 2010 2011 T1 T2 T1 T2 T1 T2 T1 T2 T1 EMR Adoption Training Prelim Notes (%) ROE Use E-Prescribing 10 scripts PCPs: 85% Specs: 80% Dept: 90% *Dept: 80% Dept: 85% MD: 85% MD: 85% Hand Hygiene JC Training Safety Rpt. or CC Training MD Communication Training Hospital HCAHP S Score Service HCAHPS Score Final Note Timeliness *Target was decreased For T1, 2009 due to adoption of more stringent measurement criteria. 24
Quarter 3 Quarter 4 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Quarter 1 Quarter 2 Quarter 3 Benefits of improved hand hygiene HH and MRSA Rates Before contact rates After contact rates MRSA Rate 100% 2.50 90% 80% 1.95 2.00 70% 1.79 60% 50% 40% 30% 20% 1.52 1.33 1.33 1.51 1.33 1.25 1.00 1.22 1.18 1.21 1.09 0.99 1.08 0.88 1.03 1.12 1.08 0.81 0.96 0.82 0.66 0.60 1.50 1.00 0.61 0.50 10% 0% 0.00 2002 2003 2004 2005 2006 2007 2008 MD hand hygiene. 2006 (Q3) Before contact: 30% After contact: 71% 2008 (Q3) Before contact: 79% After contact: 93% MRSA rate. 2006 (Q3): 1.03 2008 (Q3): 0.61 Meyer G, Torchiana D, Colton D, Mountford J, Mort E, Lenz S, et al. (Aug 2008). The use of modest incentives to boost adoption of safety practices and systems. In Henriksen K, Battles JB, Keyes MA, Grady M (Ed.), Advances in patient safety: New directions and alternative approaches (Vol 3: Performance Tools). Rockville (MD): Agency for Healthcare Research and Quality. 25
Evidence based care improvement tactics Longitudinal Care Episodic Care Primary Care Specialty Care Hospital Care Patient portal/physician portal Access program Access to care Extended hours/same day appointments Expand virtual visit options Reduced low acuity admissions Defined process standards in priority conditions (multidisciplinary teams) Design of care Measurement High risk care management 100% preventive services Shared decision making Appropriateness Chronic condition management Costs/population EHR with decision support and order entry Variance reporting/performance dashboards Quality metrics: clinical outcomes, satisfaction Incentive programs Costs/episode Re-admissions Hospital Acquired Conditions Hand-off and continuity programs Milford, CE, Ferris TG (2012 Aug). A modified golden rule for health care organizations. Mayo Clin Proc. 87(8):717-720. 26
What we measure: putting it all together Each cell in this graphic represents something we measure. We cannot measure everything, but we measure a lot. Publically reported Ongoing physician performance assessment Quality incentive program 29% Outcome Measures http://www-958.ibm.com/software/analytics/manyeyes/visualizations/new/treemap/mgh-quality-measures-2011-revised--4/1 27