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Albany 26th oct 2011

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Albany 26th oct 2011

  1. 1.  Animated Short: The Amazing Health Care Arms Race  http://www.publicradio.org/columns/marketplace/ business-news-briefs/2011/09/oh-the-jobs-youll- create.html
  2. 2. Course Objectives -participant will understand/be able to discuss the important trend of PCMH in health care -participant will understand/be able explore the rationale and supporting evidence for PCMH - participant will understand/be able understand the impact on patients, providers and payers Disclosure: – I am a full time Emplyee of IBM I WILL NOT discuss any pharmaceuticals, medical procedures, or devices I have gratefully had my expenses covered to do some of my talks about PCMH by Merck, and Pfizer.
  3. 3. New York USA 2011 Dubuque, Iowa 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 deliver system!!” - Unaccountable Care Organizations * Peter A. Muennig and Sherry A. Glied Health Affairs Oct. 7, 2010
  4. 4. The EMPIRE (of HIGH Hospital cost) State New York spends more than twice the national average on Health Care on a per capita basis New York ranks 22nd out of all states for overall health system quality Ranks last 50th of 50 for all states for avoidable hospital use and costs. Real Transformation must be pursued in collaboration across the buyers and payers Employers, State, CMS, Medicaid. Change of convenient between buyers and providers
  5. 5. Why Innovate Affordability The Elephant in the room $30,000 $28,530 Costs continue their upward climb… $25,000 …with employers still picking up much of the tab… +166% $20,000 $15,000 +118% $10,743 $10,000 $5,000 $4,918 $0 2001 2009 2019 - Employer Cost - Employee Payroll Contributions - Employee Out of Pocket Expenses a Slide From Dr Martin Sepulveda
  6. 6. Health care is a business issue, not a benefits issue Slide From Dr Martin Sepulveda
  7. 7. OUR IBM Patient needs A long-term comprehensive relationship with a Personal Physician empowered with the right tools and linked to their care team.
  8. 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
  9. 9. The Quadruple Aim Readiness, Experience of Care, Population Health, Cost Per Population Capita Health Cost The System Integrator System Integrator Creates a partnership across the medical Patient Productivity neighborhood Experience Drives PCMH primary care redesign Offers a utility for population health and financial management
  10. 10. Smarter Healthcare 36.3% Drop in hospital days 32.2% Drop in ER use -9.6% Total cost (Mayo Zero cost increase) 10.5% Inpatient specialty care costs are 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 16th 2010
  11. 11. Every country starts at the base of the pyramid with Wellness Prevention primary care, and they work their way up until the money runs out. 3 Care 3 Care 2 Care What’s 2 Care wrong with this picture? 1 Care 1 Care, Wellness Prevention … “We start at the top of the pyramid, and we work our way down until the money runs out…And so we have to change the pyramid. We have to start at the base.”
  12. 12. 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!!
  13. 13. 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
  14. 14. Trajectory to Value Based Purchasing: Achieving Real Care Coordination and Outcome Measurement Value-Based Purchasing: Reimbursement Value/ Tied to Outcome Performance on Measurement: Value (quality, Reporting of appropriate Operational Quality, utilization and Care Utilization and patient Coordination: Patient satisfaction) Embedded RN Satisfaction Primary Coordinator Measures Care and Health Capacity: Plan Care Achieve Patient Coordination $ Supportive Base Centered for ACOs and HIT Medical Bundled Home Infrastructur Payments with e: EHRs and Outcome Connectivity Measurement and Health Plan Involvement
  15. 15. HEALTH INDUSTRY -- WSJ WellPoint's New Hire. What Is Watson? IBM – WellPoint
  16. 16. And the PLAN is – CPCi by CMMI  Care management: Primary care practices will be able to proactively assess their patients to determine their needs and provide appropriate and timely preventive care.  Access and continuity: Primary care practices must be accessible to patients on a 24/7 basis and be able to utilize patient data tools to give real-time healthcare information to patients in need.  Planned care for chronic conditions and preventive care: Participating primary care practices will deliver intensive care management for the patients with high needs and create a plan of care that fits a patient’s individual circumstances and values.  Patient and caregiver engagement: Primary care practices will have the ability to actively engage patients and their families to participate in their care.  Coordination of care across the medical neighborhood: WELLBY
  17. 17. 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
  18. 18. 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  Provide open scheduling. management.  Provide care management and  Offer patient self-management coordination by specially-trained support. team members.  Provide a visit summary to the  Use an EHR with decision support. patient following each visit.  Use CPOE for all orders, test  Maintain a summary-of-care tracking, and follow-up. record for patient transitions.  Medication reconciliation for every  Email consultations. visit.  Telephone consultations.  Prescription drug decision support.  The development of care  Implement e-prescribing. plans.  Performance outcome measures.
  19. 19. Defining the Care Centered on Patient Superb Access to Care Team Care Patient Engagement in Care Patient Feedback Clinical Information Systems Publicly Available Information Care Coordination
  20. 20. “We do kidney transplants and dialysis more often than anyone, but we need to, because patients are not given the kind of coordinated primary care that would prevent chronic complications of renal and heart disease from becoming acute.” George Halvorson (CEO Kaiser) from “Healthcare Reform Now”
  21. 21. 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!
  22. 22. 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”
  23. 23. 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 $$
  24. 24. 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
  25. 25. Vermont Financial Impact IMPACT OF MEDICAL HOME SAVINGS ACROSS TOTAL POPULATION $420,000,000 $400,000,000 INCREMENTAL COST PER YEAR $380,000,000 $360,000,000 $340,000,000 $320,000,000 $300,000,000 1 2 3 4 5 YEARS
  26. 26. BCBS MA 6% decrees cost (NEJM) BCBS MI 2670 physician (BIG study) 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%
  27. 27. And Today in NY PCMH practices Avoidable emergency room visits continue downward trend, seven percent better than market. Following evidence-based medicine continues to improve, six percentage points better than market. Medical cost trend is more than seven percentage points better than market. $9 PMPM cost savings. Diabetes is better controlled, will improve long-term health and lower medical costs.
  28. 28. The Empire State Plan So simple so much  We Developed a better healthcare system starting with Public Private payers Private payers Joined  Strong Primary care is foundational to a high performing healthcare system  Additional resources needed to help primary care manage populations  Learned timely data is essential to success  Learned must build better local healthcare systems (public-private partnership)  Physician leadership is critical  Improve the quality of the care provided and cost will come down
  29. 29. 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 NNMC Medical Home
  30. 30. 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
  31. 31. 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. Citation -- 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.
  32. 32. Patients love to see meaningful information about themselves and it take 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 to them, “if you the healer make a change, it will make a difference to your patient.”
  33. 33. 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.”
  34. 34. PMPM Payment: Commercial Population Physician Practice Size Level of PCMH Recognition (# of patients) Level 1+ Level 2+ Level 3+ < 10,000 $4.68 $5.34 $6.01 10,000 - 20,000 $3.90 $4.45 $5.01 > 20,000 $3.51 $4.01 $4.51 Tier Major Condition Groups Minutes of Work PMPM PMPM Payment 0 None N/A N/A 1 3-Jan 15 $10.14 2 6-Apr 30 $20.27 3 9-Jul 60 $40.54 4 10+ 90 $60.81 38
  35. 35. Payment Model Component PMPM Payment Practice transformation cost payments (year 1 $1.67 PMPM only) Performance bonus (beginning in year 2) Up to $2.38 PMPM (value based on performance) Risk-adjustment Up to $1.67 PMPM (only for practices with above average patient panel risk profiles; amount varies by practice) Payment Model Component PMPM Payment Care management payments Up to $2.50 PMPM Pay-for-performance payments Up to $2.50 PMPM Payment Model Component PMPM Payment Practice support payments $1.50 PMPM Care management payments $0.60 PMPM (ages 0-17) $1.50 PMPM (ages 18-64) $5.00 PMPM (ages 65-74) $7.00 PMPM (ages 75+) Shared savings Value based on performance 39
  36. 36. Population management !! Accountability !! Who was the Shooter’s Doctor? Away from Episodes of Care - FFS
  37. 37. 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 by Robert S. Kaplan and Michael E. Porter Sept 2011 Harvard review