Utah hospital aug 2014

© 2014 IBM Corporation
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Paul Grundy MD, MPH - IBM Director, Healthcare Transformation August, 2014
Utah Hospitals
Better Care, Reducing Costs, Improving service
Population Health Patient Centered Medical Home

© 2014 IBM Corporation 2
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Paul Grundy MD MPH Bio
• “Godfather” of the Patient Centered Medical Home
• IBM Global Director Healthcare Transformation
• President of PCPCC
• Member Institute of Medicine
• Member Board ACGME
• Professor Univ. of Utah Department Family Medicine
• Winner NCQA national Quality Award
• A Leader of MOH level taskforce primary care transformation 8
nations: USA, Canada, New Zealand, Australia, Holland,
Denmark, UK, Belgium,
• Univ. of California MD, John Hopkins Trained

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Population
Health
System Integrator
Patient
Experience
The System Integrator
Creates a partnership across the
medical neighborhood
Drives PCMH primary care redesign
Offers a utility for population health
and financial management
Per
Capita
Cost
Public Health
Away from Episode of Care to Management of Population
Hospital
Community Health

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4
0
1000
2000
3000
4000
5000
6000
7000
1980 1983 1986 1989 1992 1995 1998 2001 2004
United States
Germany
Canada
France
Australia
United Kingdom
Average health spend per capita ($US PPP)
How do you start to fix the foundational issue around why our
healthcare system is so expensive and yet so broken??
Source: K. Davis, C. Schoen, S. Guterman, T. Shih, S. C. Schoenbaum, and I. Weinbaum, Slowing the Growth of U.S. Health Care Expenditures:
What Are the Options?, The Commonwealth Fund, January 2007, updated with 2007 OECD data

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Current Payment Systems Penalize Primary care Prevention Quality and
Reward Volume We have discover the enemy --- we buy garbage!!!! IBM
other large Buyers are demanding change in that (BIG TIME)
Preventable
Condition
Continued
Health
Healthy
Consumer
No
Hospitalization
Acute Care
Episode
Efficient,
Successful
Outcome
Complications,
Infections,
Readmissions
High-Cost
Successful
Outcome
$
Fee-for-Service Payment
Pays More for Bad Outcomes
and Less When People Stay Healthy
IBM paying first $$ primary care!!

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Reason IBM pays 1st
dollar primary care
“Not surprisingly, those patients with the strongest
relationships to specific primary care physicians were
more likely to receive recommended tests, medication
adherence and preventive care.
In fact, this sense of connection with a single doctor
had a greater influence on the kind of preventive care
received than the patient’s age, sex, race or ethnicity.”
Patient–Physician Connectedness and Quality
of Primary Care
Steven J. Atlas, MD, MPH; Richard W. Grant, MD, MPH;
Timothy G. Ferris, MD; Yuchiao Chang, PhD; and
Michael J. Barry, MD
3 March 2009 | Volume 150 Issue 5 | Pages 325-335

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“We do heart surgery more often than anyone, but we need to,
because patients are not given the kind of coordinated primary
care that would prevent chronic heart disease from becoming
acute.”
-- George Halverson’s (CEO Kaiser)
from “Healthcare Reform Now

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36.3% Drop in hospital days
32.2% Drop in ER use
12.8% Increase Chronic Medication use
-15.6% Total cost
10.5% Drop Inpatient specialty care costs
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 - PCPCC Oct 2012
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Creating Value Through Patient
Centered Medical Homes
October 22, 2009
Bob Kocher, MD
National Economic Council
Special Assistant to the President

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11
MOVING TOWARDS A MORE COORDINATED SYSTEM
11
Cooperating in new efforts to
better coordinate care
• Accountable Care
Organizations (ACOs)
• Community health teams
• HIT
Working with innovative
reimbursement structures
• Bundled payments
• Expanded pay-for-Quality
• Readmission incentives
• Outlier reductions
Improving health outcomes
• Prevention (primary and secondary)
• Chronic disease management
• Patient engagement and education
• Data transparency
Patient
Centered
Medical Homes
quality
improving/value
creating systems

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12
HEALTH INSURANCE REFORM WILL IMPROVE THE WAY CARE IS
DELIVERED FOR ALL AMERICANS
12
•Primary care has
a critical role to
play in reform
•Health insurance
reform will
facilitate adoption
of advanced
primary care
models (PCMH)
Changes to the delivery system
•Incentives quality not quantity of medical
care
•No cost sharing for preventive care
•Better coordinate care for patients with
chronic diseases
•Ensure patients receive clinically
recommended treatments and follow-up
•Reduce duplicative testing and
rehospitalizations
•Integrate with community health resources to
provide more holistic patient care
•Expand coverage and access

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Maryland July 2014 -- CareFirst saved $267 million with its medical home
• 11 percent fewer days in the hospital
• 8 percent fewer hospital readmissions.
http://www.fiercehealthpayer.com/story/medicaid-can-reap-rewards-medical-homes/2014-07-15

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Rural New York July 2014
Costs for Medicaid patients dropped from
$334 to $266, according to a recent “risk
adjusted” analysis.
http://poststar.com/news/local/medical-home-program-gains-traction/article_5811380c-2ee9-11e3-8548-001a4bcf887a.html

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•9.9 percent lower rate of adult ER visits
•27.5 percent lower rate of adult ambulatory care sensitive
inpatient stays
•11.8 percent lower rate of adult primary care sensitive ER
visits
•8.7 percent lower rate of adult high-tech radiology usage
•14.9 percent lower rate of pediatric ER visits
•21.3 percent lower rate of pediatric primary-care sensitive ER
visits
24 July 2014 Michigan Blues’ patient-centered medical home
program shows statewide transformation of care YEAR 6
4,022 primary care doctors at 1,422 practices around the state in its sixth year of
operation. These practices care for more than 1.2 million BCBSM members

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44% reduction in hospital costs
21% reduction in overall medical costs.
160 PCMH practices Pennsylvania from 2009 to 12
Number of patients with poorly controlled diabetes declined
by 45%
44% reduction in hospital costs
21% reduction in overall medical costs.
160 PCMH practices Pennsylvania from 2009 to 12
Number of patients with poorly controlled diabetes declined
by 45%
http://www.ajmc.com/publications/issue/2014/2014-vol20-
n3/Medical-Homes-and-Cost-and-Utilization-Among-High-
Risk-Patients#sthash.qR8uWb4t.dpuf
http://www.ajmc.com/publications/issue/2014/2014-vol20-
n3/Medical-Homes-and-Cost-and-Utilization-Among-High-
Risk-Patients#sthash.qR8uWb4t.dpuf
PCMH Pennsylvania June, 2014
Conclusions: PCMH practices had significantly reduced costs
and utilization for the highest risk patients, particularly with
respect to inpatient care.

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Ogden UT ,
USA 2012

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MobileFirst Patient Consumer

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Preventive
Medicine
Medication
Refills Acute Care
Nursing
Test Results
Master Builder
DOCTOR
Source: Southcentral Foundation, Anchorage AK
Behavioral
Health
Case
Manager
Medical
Assistants
Chronic Disease
Monitoring
Practice transformation away from episode of care

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Medication
Refills
Chronic
Disease
Monitoring
Test
Results
Acute
Care
Preventive
Medicine
Point of
Care Testing
Acute
Mental
Health
Complaint
Chronic
Disease
Compliance
Barriers
Healthcare
Support
Team Behavioral
Health
Medical
Assistants
Case
Manager Provider
Source: Southcentral Foundation, Anchorage
AK
PCMH Parallel Team Flow Design: the glue is real data,
not a doctor’s brain

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Today’s Care PCMH Care
My patients are those who make
appointments to see me
My patients are those who make
appointments to see me
Our patients are the population
community
Our patients are the population
community
Care is determined by today’s
problem and time available today
Care is determined by today’s
problem and time available today
Care is determined by a proactive plan
to meet patient needs with or without
visits
Care is determined by a proactive plan
to meet patient needs with or without
visits
Care varies by scheduled time and
memory or skill of the doctor
Care varies by scheduled time and
memory or skill of the doctor Care is standardized according to
evidence-based guidelines
Care is standardized according to
evidence-based guidelines
Patients are responsible for
coordinating their own care
Patients are responsible for
coordinating their own care
A prepared team of professionals
coordinates all patients’ care
A prepared team of professionals
coordinates all patients’ care
I know I deliver high quality care
because I’m well trained
I know I deliver high quality care
because I’m well trained
We measure our quality and make
rapid changes to improve it
We measure our quality and make
rapid changes to improve it
It’s up to the patient to tell us what
happened to them
It’s up to the patient to tell us what
happened to them
We track tests & consultations, and
follow-up after ED & hospital
We track tests & consultations, and
follow-up after ED & hospital
Clinic operations center on meeting
the doctor’s needs
Clinic operations center on meeting
the doctor’s needs
A multidisciplinary team works at the
top of our licenses to serve patients
A multidisciplinary team works at the
top of our licenses to serve patients
Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma

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Superb Access
to Care
Patient Engagement
in Care
Clinical Information
Systems, Registry
Care Coordination
Team Care
Communication
Patient Feedback
Mobile easy to use
and Available
Information
Defining the Care Centered on Patient

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Trajectory to Value Based Purchasing:
Achieving Real Care Coordination and
Outcome Measurement
Source: Hudson Valley Initiative

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Payment reform requires more than one method, you
have dials, adjust them!!!
“fee for health”
fee for value
“fee for outcome”
“fee for process”
“fee for belonging
“fee for service”
“fee for satisfaction”

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Give me enough medals and I'll win you any war' Napoleon Bonaparte – not
just the $Green$ that brings JOY
The Science of
Rewards, incentives

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% Total
Healthcare
Spend
% of Members
Those who are
well or think
they are well
Those with
chronic illness
Those with
severe, acute
illness or injuries
Benefit Redesign - Patient Engagement Different Strategies for
Different Healthcare Spend Segments

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IBM’s Strategy Moves Costs From Below Market to Market Leader
 Best in market purchasing strategy
 Redesigned plan mix to use PPO
model
 Employee-centric allocation of IBM
investment with dependent subsidy
reduced
 Investments in prevention, primary
care and chronic disease
management
 Employee cost sharing keeps pace
with inflation
 Award-winning wellness strategy
providing support for healthy living;
onsite screenings and
immunizations
Source for benchmarks: Average of survey results from Kaiser Family
Foundation, Hewitt Associates and Towers Perrin
4.8%
9.7%
4.5%
6.6%
10.6%
6.4%
7.0%
4.9%
2.2%
5.6% 4.6%
3.7%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
8.0%
9.0%
10.0%
11.0%
12.0%
2004
2005 2006 2007 2008
2020099
NetIBMMedicalTrend
Benchmark Net IBM Trend
$1B Saved in 6 Years

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30 © 2009 IBM Corporation6
IBM Population Risk Has Moved Toward Improved Health
 Wellness programs have had a dramatic
impact on the health of our employees
– Percentage of employees with high
health risks reduced by 55%
– Percentage at low risk increased by
double digits
 Reduction in health risks translates into
health claims cost reduction
– Represents an almost $300 reduction in
per employee costs or a $29M savings
2004 – 2007 Health Risk Assessment Participation
*$392M = 2007 dollars applied to 2004 health risk profile.
**Total costs based on 103K total self-insured population and represent
employee costs only (not including dependents)
Projected 2007 spend with no
health risk improvement
Actual
spend
$7,555
$4,638
$2,660
$392M* $363M**
$29M (7%)
difference
55.4%
68.3%
31.8%
26.0%
12.8%
5.7%
0%
20%
40%
60%
80%
100%
2004 Profile 2007 Profile
%ofAllHRAParticipants
High Risk (4+ risks)
Medium Risk (2-3
risks)
Low Risk (0-1 risk)
Shift in Health Risk Profile = Savings in Healthcare Claims Costs
Note: Includes ALL participants each year, NOT MATCHED SAMPLES
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
%ofAllHRAParticipants
High Risk (4+ risks)
Medium Risk (2-3 risks)
55.4%
59.2%
64.8% 68.3%
31.8%
30.2%
28.7% 26.0%
12.8% 5.7%10.6% 6.5%
2004 2005 2006 2007
(N=54K) (N=70K) (N=73K) (N=75K)
Low Risk (0-1 risk)
$363M
$369M
$383M
$401M
$398M
$395M
$392M
$340
$360
$380
$400
$420
2004 2005 2006 2007
IBMMed&RxPaidClaimsCosts($M's)
(Calculatedbasedon2007dollars)
2005 2006 2007
3 Year
Total
Est. savings between IBM
health risk improvement &
expected risk increase
$12M $29M $38M $79M Total
Wellness programs have had a dramatic impact on
the health of our employees ‘04 to ’07
High health risk population reduced 55%
Low health risk population increased 23%
Reduction in health risks translates into savings in
health claims costs compared to expected trends
with no wellness interventions
$279M estimated savings for 2004 to 2013 period
Expected cost increase
with no IBM population
health risk improvement*
With actual IBM
population health risk
improvement**

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Public Health
Prevention
Specialists
PCMH 2.0 in Action
Community Care Team
Nurse Coordinator
Social Workers
Dieticians
Community Health Workers
Care Coordinators
Public Health Prevention
HEALTH WELLNESS
Hospitals
PCMH
PCMH
Health IT
Framework
Global Information
Framework
Evaluation
Framework
Operations
A Coordinated
Health System
35

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2009 2010 2011 2013 2014
Percentage of Vermont
population participating 6.7% 9.8% 13.0% 42.0% 86.0%
Participating population 42,179 61,880 82,332 227,045 654,852
# Community Care Teams 2 3 4 6 11

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33
The New Yorker: The Cost Conundrum June 1st
2009
• When you look across the spectrum from Grand Junction to McAllen you see A
threefold difference in the costs of care—
• you come to realize that we are witnessing a battle for the soul of American
medicine. Somewhere in the United States at this moment, a patient with chest
pain, or a tumor, or a cough is seeing a doctor. And the damning question we have
to ask is whether the doctor is set up to meet the needs of the patient, first and
foremost, or to maximize revenue.
• The lesson of the high-quality, low-cost communities is that someone has to be
accountable for the totality of care. Otherwise, you get a system that has no brakes.
You get McAllen.
• The foundation of this is at the Micro level someone has to be Accountable for your
care -- that is the PCMH in most of the civilized world !!!
• primary care doctors per 100,000 Grand Junction, 106, McAllen has just 45
• OR WHERE is the ADULT supervision!!!

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Healthcare Will Transform
Data Driven
Every person has a plan
Team based
Managing a population
down to the person
.

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Hospital
Payer
EmployerCommunity
Government
Primary
Care
Provider
Other
Caregivers
Pharmaceutical
Manufacturers
Nurse
Specialists
Social
Worker
PCMH
Patient
The PCMH model impacts stakeholders across the
continuum of care
Pharma: Improved communication
platforms and relationships with
healthcare providers, patients and
payers; increased sales through
improved patient identification,
diagnosis, and treatment;
recognized as a key player in the
patient health delivery value chain
Payer: Improved member and employer
satisfaction, lower costs, opportunity for
new business models
Employer: Lower
healthcare costs, more
productive workforce,
improved employee
satisfaction
Government: Lower
healthcare costs, healthier
population
Patient: Better, safer, less costly, more
convenient care and better overall health,
productive long-term relationship with a PCP
Primary Care Provider:
Increased focus on the patient
and their health, greater access
to health information; higher
reimbursement; more PCPs
Specialists: Better referrals,
more integrated into whole patient
care, better follow up less re-
hospitalizations
Hospital: Lower number
of admissions and re-
admissions for chronic
disease patients; able to
focus on acute care issues

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1. Pursue Electronic Patient Management
and engagement rather than Electronic Patient
Records
2. Bring to bear upon every patient
encounter what is known rather than what a
particular provider knows.
3. Make it easier to do it right than not to do
it at all.
4. Continuous performance improvement.
5. Infuse new knowledge and decision-
making tools throughout an organization
instantly.

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6. Establish and promote continuity of care with patient
education, information and plans of care.
7. Enlist patients as partners and collaborators in their own
health improvement.
8. Evaluate the care of patients and populations of patients
longitudinally.
9. Audit provider performance based on the Consortium for
Physician Performance Improvement Data Sets.
10. Create multiple case-management tools which are
integrated in an intuitive and interchangeable fashion giving
patients the benefit of expert knowledge about specific
conditions while they get the benefit of a global approach to their
total health

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Practices Features -- - Emphasis on care coordination and
system navigation, System Integrator, PCMH role for family
physician in integrated system - Big push on population health
management - Care teams with PCP + a variety of other
professions, e.g., nursing, pharmacy, public health and mental
health.
Technology Use - Better population health data stemming from
centralized data based EHR through integrated system. -
Adoption of telemedicine, Establish Primary Care Technology
Center (PCTC), a research and training entity, to fuel adoption
of efficacious technology in practice, patient engagement tools.
Modern, flexible, sophisticated system, developed in partnership
with technology providers. -Multi-modal communication w/
patients .

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Building a Workforce -- Training in the use of population
health management, data management and public health
tools - Dual degrees – MD + MBAs, MPHs - .Add’l training in
interprofessional collaboration, EHR data usage, and
integrated practice management.
Research Focus -- Conclusive evidence about system wide
quality improvement and cost savings of robust primary
care.- Rise of Continuum-Based Research Networks, applied
research efforts to improve clinical pathways. - Research
builds case for reductions in Total Cost of Care (at system
level), research into technologies most inpactful on Triple
Aim. - FM becomes trusted source of best practices to meet
Triple Aim, .Focus on issues that relate to patients owning
their own health through patient experience and engagement
research

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Collaboration -- - Family medicine’s partnership with payers
and the integrated systems, to exchange ideas about how to
best deploy family physicians and represent their colleagues’
interests to these systems - Subspecialists – to ensure great
working relationships within systems. - Primary care
professionals – to achieve the best possible outcomes in
service of Triple Aim. Payers, particularly CMS – to ensure
success of alternative payment pilots.- Primary Care Nurse
Practitioners (to work together in pursuit of expanded role of
Primary Care, Technology manufacturers) to provide advice
on how to improve technology in use by FPs,
Key Investments -- Curricular overhaul and research effort to
prepare residents for work in integrated systems, tools for
data being made into actionable information in population
management, advance clinical decision support

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Thank you

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A comprehensive approach helps reduce costs while improving care
Apply new insights from
interactions and outcomes
to enable continuous
transformation
LEARNING
Identify and influence individuals
and populations, and recognize
intervention opportunities
INTERVENTION
COORDINATION
Deliver care and monitor progress
across clinical and social
requirements
COLLABORATION
Assess and engage
individuals and
stakeholders to drive
individualized care plans
Drive evidence-based and
standardized care planning
KNOWLEDGE
WELLNESS
43

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Trademarks and notes
© IBM Corporation 2014
• IBM, the IBM logo, ibm.com, and Cúram are trademarks or registered trademarks of International Business
Machines Corporation in the United States, other countries, or both. If these and other IBM trademarked terms are
marked on their first occurrence in this information with the appropriate symbol (®
or ™
), these symbols indicate U.S.
registered or common law trademarks owned by IBM at the time this information was published. Such trademarks
may also be registered or common law trademarks in other countries. A current list of IBM trademarks is available on
the Web at “Copyright and trademark information” at ibm.com/legal/copytrade.shtml.
• Other company, product, and service names may be trademarks or service marks of others.
• References in this publication to IBM products or services do not imply that IBM intends to make them available in all
countries in which IBM operates.

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Objectives
1) Participant will understand/be able to discuss the
important trend of PCMH in health care

2) Participant will understand/be able to explore the
rationale and supporting evidence for PCMH

3)Participant will understand/be able comprehend the
impact on patients, providers and payers
Disclosure – I am a full time Employee of IBM –IBM and
other PCPCC executive member companies have
supported by talks on PCMH.

Utah hospital aug 2014

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