Utah sept 2012 (cmprssd)

University of Utah 2012

Paul Grundy, MD, MPH, FACOEM, FACPM
IBM Director Healthcare Transformation
President Patient Centered Primary Care Collaborative

Trip to Denmark July 10 2009

Copyright 2011 by IBM
1

In Alaska in Utah –PCMH CARE by Design
 The “foundation” has achieved startling
efficiencies is the most advanced locations:
 Emergency room use has been reduced by 50 percent,
 Hospital admissions by 53 percent,
 Specialty care visits by 65 percent.These efficiencies, in
turn, have clearly saved money
 60% Reduction in Complications of Diabetics

And Patients Not Shortchanged
 Patients are virtually guaranteed a doctor’s
appointment on the day they request it, and their calls
are answered quickly, usually within 30 seconds.
 The percentage of children receiving high-quality care
for asthma has soared from 35 percent to 85 percent,
 The percentage of infants receiving needed
immunizations by age 2 has risen above 90 percent,
 The percentage of diabetics with blood sugar under
control ranks in the top 10 percentile of a standard
national benchmark, and customer and
 Employee satisfaction rates top 90%.

The Right Design
Designed Right here in Utah

THE PCMH foundation of the Triple Aim
Readiness, Experience of Care, Population Health, Cost

Per
Population Capita
Health Cost The System
Integrator
System Integrator
Patient Productivity Creates a partnership
across the medical
Experience
neighborhood

Drives PCMH primary
care redesign

Offers a utility for
population health and
28 financial management

Why Innovate? Affordability
The elephant in the room

166%

118%

2001 2009 2019
Costs continue their upward climb with employers paying much of the tab
- Employer Cost - Employee Payroll Contributions - Employee Out of Pocket Expenses
Source: Dr. Martin Sepulveda Copyright 2011 by IBM
5

USA 2012

Ogden Utah
SLC Utah

The Cause? Mostly due to unregulated fee-for-service payments and an over reliance on
rescue/specialty care. This is stark evidence that the U.S. health care Industry has been
failing us for years “Commonly cited causes for the nation's poor performance are not to
blame - it is the failure of the delivery system !!”

- Unaccountable Care Organizations

20 *Source: Peter A. Muennig and Sherry A. Glied Health Affairs Oct. 7, 2010 Copyright 2011 by IBM

VA Outranks Private Sector in Health Care Patient Satisfaction

Thirteen Year Cumulative Percent Change in Cost

VHA Cost Per
Patient Total
Medical Care
Obligations per
Total Unique
Patients (including
non-Veterans)

Average Medicare
Payment Per
Enrollee
Medicare Program
Benefits per
Enrollee

Consumer Price
Index
Bureau of Labor
Statistics
All Urban
Consumers

11

Montana Governor Schweitzer opens new state
employee Medical Home primary care clinic

Why would hospitals perform unnecessary heart surgery?
Because it pays!!.
looked at cardiology procedures done. They found that 43 percent should
not have happened Washington Post -Sarah Kliff on August 7, 2012 at 9:56 am

New York Times Sept 2012: PuttingProfits Before Patients ---
disturbing pattern of superfluous heart surgeries that put
patients' lives at risk without any evidence of value
August 27, 2012, New York, Times
Over treatment Is Taking a Harmful Costly Toll
By TARA PARKER-POPE
costing the nation’s health care system at least $210 billion

Somebody has to do something, and it's
just incredibly pathetic that it has to be us.

Build your own corporate PCMH

Per Employee Per Month
$805 $804
Health Costs
$765
Post Implementation

Actual client data: Midwest Hospital
with 12,135 employees 1 year self- $569
funded for group health

17

WellPoint's New Hire - What at Is Watson?

19

Practice Transformation Away
Episode of Care Flow Design
Chronic
Preventive Disease Medication
Medicine Monitoring Refills Acute Care Test Results

DOCTOR

Healthcare
Support
Team Case Behavioral Medical
Nursing
Manager Health Assistants

Source: Southcentral Foundation, Anchorage AK

Healthcare Industry is beset with some of the most complex
information challenges we collectively face –In fact the current
structure has failed us.
Medical information
is doubling every 5
years, much of which
is unstructured

81% of physicians
report spending 5
hours or less per
month reading
medical journals

Source: International Journal of Circumpolar Health, DoctorDirectory.com, Institute for Medicine"

PCMH Parallel Team Flow Design
The glue is data – just like banking
Chronic Acute Point of Chronic
Disease Care Care Testing Disease
Monitoring Compliance
Acute Barriers
Test Preventive Mental
Medication Results Medicine Health
Refills Complaint

Healthcare
Support
Case Medical Behavioral
Team Clinician
Manager Provider Assistants Health

Source: Southcentral Foundation, Anchorage AK

Benefit Redesign - Patient Engagement
Different Strategies for Different Healthcare Spend Segments

Those with
severe, acute
illness or injuries

% Total
Healthcare
Spend
Those with
chronic illness
Those who are well or
think they are well

% of Members 21
21

Payment reform requires more than one method,
you have dials, adjust them!!!

“fee for health”

“fee for outcome”

“fee for process”

“fee for belonging

“fee for service”

“fee for satisfaction”

32

FEHB Program Carrier Letter All Carriers
U.S. Office of Personnel Management-Federal
Employee Insurance Operations -Letter No.
2012-09

 We are reinforcing our support for patient
centered medical homes (PCMH). We are
again calling for to increase FEHBP
members’ access to primary care
providers who have adopted the principles
of the medical home.

29 March 2012

OPM $39 Billion Book with Accountable Care
Patient at the Center
 24-7 clinician phone response  Pre-visit planning and after-visit
follow-up for care management.
 Provide open scheduling.
 Offer patient self-management
 Provide care management and support.
coordination by specially-trained team
members.  Provide a visit summary to the
patient following each visit.
 Use an EHR with decision support.
 Maintain a summary-of-care
 Use CPOE for all orders, test tracking, record for patient transitions.
and follow-up.
 Email consultations.
 Medication reconciliation for every
visit.  Telephone consultations.
 Prescription drug decision support.  The development of care plans.
 Implement e-prescribing.  Performance outcome
measures.

31

Multi-state and National exchange
- Section 1334 of the ACA
 OPM base of the multi-state exchange and the national exchange --
everyone is so focused on the states they miss the fact that OPM
under the law is the agent for the other two exchanges it is built on
this carrier letter.
 OPM requirements are found in Section 1334 of the ACA for OPM
to contract with health insurers to offer multi-state qualified health
plans ("MSQHPs") to the individual and small-group markets.
 The contours of OPM's implementation of the MSQHP contracts
will have a significant impact on health insurance issuers that will
participate in the state-based "American Health Benefit Exchanges"
("Exchanges") for the individual and small-group markets.

CPCI Five Functions/Framework For
Comprehensive Primary Care
 Risk stratified care management
 Access and continuity (24/7 with EMR)
 Planned care for chronic conditions and preventive care
(proactive management)
 Patient and caregiver engagement
 Coordination of care across the medical neighborhood

Payment includes $20.80PMPM

26

The World Changed Jan 27th 2012
 Insurer WellPoint to revamp primary care pay
January 27, 2012 The Associated Press
 An Rx? Pay More to Family Doctors WellPoint to invest 1
Billion in primary care transformation.
 “Patient Centered Medical Home” model
emphasized in Anthem initiative
 UNITED HC see you 10 raise you
 Conversation with OPM Yesterday - Ways and
Means and what that means

The Foundation: Patient Centered Primary Care
WellPoint strategy will drive transformation to a patient-centered care model by aligning
economic incentives and giving primary care physicians the tools they need to thrive in a
value-based reimbursement environment.

Benefit design Expanded Aligning care Exchange of
tied to access through management meaningful
measurable innovation with the information
behavior delivery system
changes and
outcomes

Four Foundational Pillars

WellPoint - Patient Centered Primary Care (PC2)
Strategy – A bold and aggressive plan

This strategy represents an aggressive and fundamental shift
in how we interact with and engage primary care physicians on all levels:
clinically, contractually, operationally and culturally.

PCMH Preliminary Year 2 Highlights In Sept
Issue Health affairs 2012

 18% decrease in acute IP admissions/1000,
COLORADO compared to 18% increase in control group

 15% decrease in total ER visits/1000, compared
to 4% increase in control group

 Specialty visits/1000 remained around flat
compared to 10% increase in control group
NEW HAMPSHIRE

 Overall Return on Investment estimates
ranged between 2.5:1 and 4.5:1

New York

NCQA PCMH Recognition Pioneered by Univ of Utah

OUR Patient needs A long-term
comprehensive relationship with a
Personal Physician empowered with the
right tools and linked to their care team.

8

The Joint Principles: Patient Centered Medical Home
 Personal physician - each patient has an ongoing relationship with a personal
physician trained to provide first contact, and continuous and comprehensive care
 Physician directed medical practice – the personal physician leads a team of
individuals at the practice level who collectively take responsibility for the ongoing
care of patients
 Whole person orientation – the personal physician is responsible for providing for
all the patient’s health care needs or arranging care with other qualified
professionals
 Care is coordinated and integrated across all elements of the complex
healthcare community- coordination is enabled by registries, information
technology, and health information exchanges
 Quality and safety are hallmarks of the medical home-
Evidence-based medicine and clinical decision-support tools guide decision-making;
Physicians in the practice accept accountability voluntary engagement in
performance measurement and improvement
Enhanced access to care is available - systems such as open scheduling,
expanded hours, and new communication paths between patients, their personal
physician, and practice staff are used
 Payment appropriately recognizes the added value provided to patients who
have a patient-centered medical home- providers and employers work together to
achieve payment reform
9

From Episode of Care to Population Management at
the Personal level Centered on the Patient

+ + =
Instrumented Interconnected Intelligent

An opportunity to think and act in new ways—
Not master-builder but Master plan DATA DRIVEN
OUTCOMES based!!

Defining the Care Centered on Patient

Superb Access
to Care
Team Care

Patient Engagement
in Care
Patient Feedback

Clinical Information
Systems, Registry
Publicly Available
Information
Care Coordination

30

Smarter Healthcare

36.3% Drop in hospital days
32.2% Drop in ER use
12.8% Increase Chronic Medication use
-9.6% Total cost (Mayo Zero cost increase)
10.5% Inpatient specialty care costs down
18.9% Ancillary costs down
15.0% Outpatient specialty down

Outcomes of Implementing Patient Centered Medical Home
Interventions: A Review of the Evidence from Prospective Evaluation
Studies in the US K. Grumbach & P. Grundy, November 16 th 2010

13

PCMH at CareMore
 a hospitalization rate 24 percent below average
 hospital stays 38 percent shorter
 an amputation rate among diabetics 60 percent
lower than average
 most remarkable of all, these improved outcomes have
come without increased total cost
 Would Zsa zsa still have a leg to stand on your MOM??

14

10
Trained &
Engaged
Leadership
9 8
Template Coordination
of the of care
future
7
5 6
Building Blocks of High-Performing Prompt
Primary Care Population Continuity
April 2012 Center For Excellence in Primary Care
access to
Management of care
care
1
2 3 4
Shared
Data-driven Empanelment Team-
Vision & & panel size
Improvement based
Goals management
care

Trajectory to Value Based Purchasing:
Achieving Real Care Coordination and
Outcome Measurement

Registry
34

PCMH in Action
Vermont “Blueprint” model

A Coordinated
Hospitals Health System

Community Care Team
PCMH
Nurse Coordinator
Social Workers Health IT
Specialists Dieticians Framework
Community Health Workers
Care Coordinators Global Information
PCMH
Framework
Public Health Prevention
Public Health HEALTH WELLNESS Evaluation
Prevention Framework
Operations

35

Horizon BCBS NJ Patient-Centered Medical
Homes Drive Quality and Cost Improvements
152 physicians at 22 practices within ten counties.

Quality Measures
 8% higher rate in improved diabetes control (HbA1c)
 6% higher rate in breast cancer screening
 6% higher rate in cervical cancer screening
Cost and Utilization Indicators
 10% lower cost of care (per member per month)
 26% lower rate in er visits
 25% lower rate in readmissions
 21% lower rate in inpatient admissions

10 April 2012

Don’t handle your care needs in a BAD MEDICAL NEIGHBORHOOD!!

Unaccountable care, lack of organization, DO NOT GO THERE ALONE !!

Be wise when you pay for care, KNOW WHAT YOU BUY!!

21

BCBS MI 2670 physician (BIG study)

WAYS AND MEANS
2010 2011
Adults (18-64)

ER visits -6.6% -9.9%
Primary care sensitive
ER Visits -7.0% -11.4%
Ambulatory care
sensitive
Hospitalizations (per
1,000) -11.1% -22.0%
BCBS MA 6% decreased cost (NEJM)
12

Cost of Commercial lives
Least Expensive Most Expensive
 Ogden, UT $2,623  Anderson, IN $7,231
 Dubuque, IA $2,719  Punta Gorda, FL $7,168
 McAllen TX $2,950  Racine, WI $6,528
 Providence $6,367
 Naples, FL $6,312
 Ocean City, NJ $6,128

22

Coordination -- we do NOT know how to play as
a team
“We don't have a health care delivery system in this country. We
have an expensive plethora of uncoordinated, unlinked, micro
systems, each performing in ways that too often create sub-optimal
performance, both for the overall health care infrastructure and for
individual patients." George Halvorson, from “Healthcare Reform Now”

26

Benefit Plan
Paid Claims – Calendar Year 2010

% Total
Healthcare
Spend Ten percent of the
population consumes
66% of the total spend
(members with >
$10,000 in expenses)

49% of the population
consumes only 4% of
the total spend (each
spends < $1,000)

% of Members
49

OPM requesting PCMH level care
 OPM Technical guidance 19 April 2012 requires all Plans to Submit:
 Criteria for PCMH recognition
 Percent and listing of all plans that have reached certification
 Number of covered lives in PCMH
 Recommended Provider payment incentives
 Plan to invite Patient into PCMH level care
 Quality outcomes associated with PCMH
 Inclusion in all CMS and state PCMH initiatives efforts (like CPCi , MAPC).

CMS Plus most other buyers

11% CMS Shift in payment away from FFS
to other dials.

CMS Bundling!! CMS Advanced Primary Care
Wellpoint PCMH, BCBS Hawaii no new FFS $$

33

If you scan the world for value based healthcare, you will find a
common element: a relationship-based team with a project
manager! A comprehensivist that can command and control
in an accountable system.

So simple!
So much!

29

PCMH level Clinic Competitive Advantage

Annual per employee group health savings
Advantage grows dramatically over time
$9,420 per
employee

$7,264 per
employee
$5,486 per
Expected employee

$4,025 per
employee
$2,830 per
employee Expected with Clinic

Years of PCMH implementation Savings per employee

18

Enhancing Health and the Patient Experience

Medical Home
Model Team-Based
Care that is Healthcare
Delivery
Accountable Population
Access to
Care Health

Advanced IT
Patient
is the center Patient-Centered
Systems of the Care
Medical Home

Decision Refocused
Support Tools Medical Training
Patient &
Physician
Feedback
Model adapted from the
39 NNMC Medical Home

PATIENT CENTERED MEDICAL HOME:
VHA Patient Aligned Care Team
Replaces episodic care based on illness and patient
complaints with coordinated care and a
long term healing relationship

40

Individual Behaviors with
Payment and Benefit Reforms

Fee for Service Bundled Payments Shared Savings Global
Capitation

Tiered networks Tiered networks Tiered networks Gatekeeper
Benefit Plan Steerage Member obligations

Autonomy Autonomy “Attribution” “Assignment”
Patient choice of providers

Well understood by payers Complex Extremely complex Well understood by some
and providers providers and payers
Administrative complexity

Minimal Moderate Substantial Substantial
Risk to Providers

Ability of providers to No incentive Substantial within the bundle Uncertain Substantial across
manage utilization and
outcomes

Minimal at best Built into budget for bundle Timing issue Supported
Support for care
management

Substantial, even with Controlled Substantially controlled Can be totally controlled
Risk to payers external UM within the cap budget

57

According to the study by NEHI, U.S. health care costs are wildly out of alignment with the actual determinants of health. About 50 percent of health status is
determined by diet, exercise, smoking, stress and safety—or lifestyle choices and available options; 20 percent by exposure to environmental toxins; 20
percent by genetic predisposition; and just 10 percent by access to health care. Yet the vast majority—88 percent—of Americans’ health dollars are spent on
access to care and treatment, with just four percent spent on lifestyle options and choices and eight percent on environmental and genetic factors. This
mismatch results in higher and higher costs for less and less health benefit. While many Americans believe that our health care system is the best in the
world, the fact is that our health relative to other nations, which spend much less per capita, is slipping, even for survival rates among adults age 45–55.

Reinventing Medicaid findings are Outstanding
 Oklahoma's patient-centered medical home initiative has reduced
Medicaid costs $29 per patient per year from 2008 to 2010. Moreover,
use of evidence-based primary care, including screening for breast and
cervical cancer, increased.
 The Colorado initiative expanded access to care. Before the initiative, only
20 percent of pediatricians in the state accepted Medicaid; as of 2010, 96
percent and did and at a lower cost to the state.
 Vermont, inpatient care use and related per-person per-month costs
decreased 21 percent and 22 percent, respectively, from July 2008 to
October 2010. ER use and related per-person per-month costs decreased
31 percent and 36 percent, respectively.
 Patient Centered Medical Home in Washington in State Acute care
spending there was 18 percent below the national average.
Inpatient stays per beneficiary were 35 percent below the national average.

The Bottom Line in Medicaid
PCMH starting to show an impact in access to care, quality, and cost control .

Source -- M. Takach, "Reinventing Medicaid: State Innovations to Qualify and Pay for Patient-Centered
Medical Homes Show Promising Results," Health Affairs, July 2011 30(7):1325–34. Copyright 2011 by IBM
41

PCMH is non-political – the right POV
for delivery transformation
“We never abandoned advocating new
Models of care. We’ve long pushed folks
to realize that Delivery reform is the key.”
The patient-centered medical home is
core.

“We included the attached
chapter on PCMH in our book.
and have a new publication on
ACOs coming out in January.”

44

Total Hospital and Physician Costs for
Select Surgeries – International Comparisons
US
US
CAN FRA GER NETH SPA SWIZ UK (95th
(avg)
%ile)

Appen-
$3,810 $2,795 $3,285 $4,624 $2,537 $2,570 $3,476 $13,123 $25,344
dectomy

Hip
Replace- $10,753 $12,629 $15,329 $12,737 $9,327 $6,683 $9,637 $34,454 $75,369
ment

Bypass
$22,212 $16,325 $27,237 $19,180 $15,802 $11,618 $13,998 $59,770 $126,182
Surgery

Source Int’l Federation of Health Plans:2010 Healthcare Price Report Copyright 2011 by IBM
25

Patients love to see meaningful information about
themselves and it takes IT tools to
 If you give patients educational materials with their
name on it and with their data analyzed in it, they
will read it, pour over it and discuss it with you.
 If you tear off a generic sheet and give it to them, it
often goes in the waste basket.
 If you give patients an analysis of their health risk AND
if you include a “what if” scenario, i.e., what will their
health risk be if they make a change; you can prove it to
them
 “If you the healer make a change, it will make a
difference to your patient.”
43

If we truly want to understand costs and where they can be reduced
without compromising outcomes, we need to aggregate costs around
the patient. (need a place to do that – that is PCMH)

The way care is currently organized leads to redundant administrative
costs, unnecessary and expensive delays in diagnosis and treatment,
and unproductive time for physicians.

A system integrator a place where data is aggregated, understood and
held accountable at the level of the individual patient -- THAT IS
PCMH.

In fact, cost reduction will often be associated with better outcomes.
The Big Idea: How to Solve the Cost Crisis in Health Care,
Robert S. Kaplan and Michael E. Porter Sept 2011 Harvard Review

6

ACO and the Principles of
the PCMH

Whether building a community-wide ACO or a solo primary care practice,
adherence to guiding PRINCIPLES provides the foundation. Through the PCMH
Joint Principles, we (the buyers and providers) have agreed to change our
covenant with one another. The Joint Principles of the PCMH have been agreed
on by those who deliver comprehensive care (the primary care providers) and
their specialist colleagues. For Accountable Care to achieve its goals, successful
organizations will NEED a foundation in these principles.

As a buyer, I want to be assured that the
foundation - the principles - are in place:
a personal relationship with a healer,
improved access, care that is coordinated,
integrated and comprehensive.
10

PCMH is the patients view from the bottom up. The kind of
care they want: relationship, accessible, coordinated

From the System view
it is ACO

Or, like the Euro tunnel you can start on one side building
PCMH and the other side ACO, but somewhere you have
to meet in the middle, where care is delivered- centered on
the needs of the patient.
11

Cost per Case $1548 savings per
Comparison case after contract
implementation
$2085 savings per $3105 savings per
case after contract case after contract
implementation implementation Savings
Gap

Savings
Gap Savings
Gap
$1231 savings per
case after contract
implementation

Savings
Gap

16

Population
management !!

Accountability !!

Who was the
Shooter’s Doctor?

Away from
Episodes of Care -
FFS
3

Parachute use to prevent death and major
trauma related to gravitational challenge;
systematic review of randomised controlled
trials.

Here is
None _
Why ??

Smith GC, Pell JP. BMJ 327:1459-1461; 2003.

Computerworld Solution
Honors Laureate

NCQA

Dept of State
Superior Honor
Award

Paul Grundy, MD, MPH, FACOEM, FACPM
IBM Director Healthcare Transformation
President Patient Centered Primary Care
Collaborative

Utah sept 2012 (cmprssd)

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