Population Health for Accountable Care: A Parable

Population Health for
Accountable Care
May 7, 2012

Confidential: Not for duplication or distribution. Subject to revision.

A Population Health Parable
Over the last forty years, a rural New England county has achieved the highest health status rank, the lowest chronic disease risk factor
levels, and the lowest mortality rate in the state. For 2011, the county was ranked first in the state in health outcomes, despite relatively
higher levels of poverty, by the University of Wisconsin Population Health Institute.

Health Status Rank
Cumulative Risk Factor Rankings Mortality Rate in
Ten Years, by County
16 16 Four Years, by County Deaths per 10,000
15 15 Ten Years, by County
14 14
13 13 620
12 12
11 11 600
10 10
9 9 580
8 8
7 7 560
6 6
5 5
4 4
540
3 3
2 2 Smoking Weight 520
1 1
Blood Pressure Cholesterol 500

American Journal of Preventive Medicine (Record, N.B.; et al. American Journal of Preventive Medicine 19(1):30-38, 2000) and highlighted by the American College of
Cardiology in the report of its 33rd Bethesda Conference (Task Force #3, Preventive cardiology: How can we do better? Presented at the 33 rd Bethesda Conference, Bethesda,
MD, December 18, 2001, Journal of the American College of Cardiology 40:579-651, 2002).

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A Corporate Health Parable
In two years, a corporate health initiative employing the same program achieved 75% participation (2,553 employees and dependents),
increased the number of healthy participants by 15%, and reduced annual growth in direct health care costs to less than 4%. Recent
research shows a greater than three-to-one return on investment for comparable programs.

Growth in Direct Annual Health Change in Number of Employees
Care Costs Attaining Goal
Weight 4%
25%
Exercise 22%
Diet 17%

12% Depression 5%
Tobacco Use 20%
4%
Cholesterol 23%
Blood Pressure 17%
Start Year 1 Year 2

$ 3.27
Return on Investment
On average, employee health care costs fell
by $3.27 for every $1.00 spent on
employee wellness programs.*
* HEALTH AFFAIRS 29, NO. 2 (2010): ©2010 Project HOPE—The People-to-People Health Foundation, Inc.
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Shared Success Factors

Structured
Trained and Actionable
Program Assessed and
Equipped Health
Methodology Engaged
“Care Assessment
and Health Users
Partners” Technology
Management

“Care partners” who A health status A program Assessed, engaged,
combine skills in health assessment and management and more literate
assessment, reports that model combining health users with the
motivational address health “high touch” agency and data to
interviewing, empathic risks and actions in services delivery support more
attention, and active the context of and a campaign rational and effective
listening to collect clinical approach to user health decisions
comprehensive health effectiveness and engagement and
information and regulatory health assessment
engage health users compliance

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So What?
Four federal programs (value-based purchasing, meaningful use of electronic records, avoidable hospital readmissions and the creation of accountable care
organizations) will significantly impact hospitals through the use of Medicare penalties and incentives. In order to qualify for the incentives and avoid penalties,
hospitals will have to go beyond simple "check-box" processes and employ new patient engagement strategies that actually work to improve outcomes and the overall
patient experience. Progress to-date is not encouraging.

 Historical fee-for-service, or volume-based, reimbursement has produced
– health plans serving “members” whose financial risk must be managed, through benefit
design, enrollment and utilization management
– health providers serving “patients” whose clinical needs must be met by discrete, billable
encounters, procedures and other episodes
 Accountable or value-based healthcare requires that delivery systems assume the financial risk of
an assigned population’s health care, previously the domain of health plans. More than 160 such
accountable care organizations are making that shift today and the number is growing.
 This shift has exposed a gap in the accountable care continuum -- the process of enrollee
engagement and assessment. Neither the traditional enrollment process nor the primary care
encounter
– engages health users sufficiently to “own” their health status and advance that sense of
health agency;
– conducts a comprehensive health risk assessment; and
– develops - with the patient – and manages a personalized prevention plan with anything
approaching population health levels of participation and management.
 While CMS reimburses annual wellness visits and preventive services through Medicare, Medicaid,
and commercial plans, few providers accommodate them, citing lack of structure, process
familiarity, system fatigue, and discomfort conducting the assessments and using preventive
services strategically, systematically, and comprehensively.
 Health systems do proceed, however, to invest in related, more costly, technology, service capacity,
and human capital initiatives that will be hampered by their absence.

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Assessment and Engagement: The Missing Step

Enrollment & Assessment & Encounter &
Verification Engagement Care Delivery

Pre-Enrollment: Pre-Engagement Pre-Encounter
• Form conversion • Target patient, provider, and site selection • Patient call for appointment
• Applicant eligibility • Provider-patient concentration • Practice call for follow-up
Enrollment: • Geographic concentration • Referral
• Member Eligibility Verification • Payor concentration Encounter
• Member Enrollment • Data sourcing, extraction, and pre-population • Primary Care
• Application processing • Systems of record (EMR, patient accounts, • “First contact” care
• Enrollment reconciliation registries, scheduling, clinical ancillary)
• Evaluation &
• Member Management • Demographics, relevant assessment data
management
• Payment reconciliation Engagement
• Continuous (ongoing)
• Risk Management • Invitation, scheduling, confirmation
care
• Suspect Claims • Assessment
• Chart Analysis • Draft personal health plan • Coordinated care
• Coordination of benefits (COB) • PCP-patient review, as needed • Comprehensive care
Post-Enrollment: Post-Engagement • Specialty Care
• Data, eligibility, and payment • Data services • Primary care referral
verification with CMS or health • Validation • Self-referral
• Post-enrollment education • Provider review • Emergent Care
• Entry in systems of record
• Reporting and visualization
• Clinical demand planning
• Visit prioritization
• Capacity planning and service line impact


Agentic Health – Turnkey Assessment and Engagement

 Assessment and Engagement  Program Management
– Practice integration and enrollee – Source, train, equip, and
outreach mobilize care partners
– Welcoming the patient to the – Maintain assessment software
program, conducting the and hardware
assessment, and preparing the – Optimize logistics of site,
personal prevention plan provider, and enrollee matching
– Completing reports for – Pre-populate assessments with
individual, primary provider, and data currently available from
employer (at appropriate levels insurers’ data and providers’
of detail and confidentiality) systems of record
– User guidance on highest value – Ensure availability of completed
actions to improve their health data sets to EMRs, patient
– Follow-up accounts, registries, scheduling
apps, and other systems of
record

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The Care Partner
Agentic Health trains Care Partners in the skills required to conduct the health assessment and engage health users and their
providers in understanding their health and the best actions they can take to improve it.

 Competency in “person-centered” care where  Motivational interviewing and active listening
important care support services are provided – Informing and emboldening the patient
outside the healthcare system as a shared decision-maker
– Family support guidance and ongoing – Uncovering barriers to change that
access by telephone or email include physical pain, emotional
– Knowledge of and guidance regarding difficulties, financial concerns, and lack of
access to community services that confidence in one’s ability to change
address the risk factors that are the focus – Assistance in patients setting realistic
of the assessment, including, where goals, self-monitoring, harnessing support
established, local Area Agencies on Aging systems, and engaging their care provider
and Aging Disability Resource Centers. effectively
– Knowledge of and guidance regarding
other community support functions  Provider and practice support and engagement
including home delivered meals, – Engaging the care team to use
transportation for shopping, program assessment reports to prioritize and
eligibility and benefit counseling, highlight patients’ health risks and
translation services, respite care, and appropriate action steps
fitness programs
– With appropriate privacy protections,
 Cultural competency, respecting individuals’ aggregating assessment data for use by
beliefs, understanding the cultural context in individual physicians, provider practices,
which they experience illness and health, and health facilities, and accountable care
developing a collaboratively set health plan organizations for performance
improvement

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The Assessment: Compliance in Design and Process*
 Demographics and limited family/personal
health history
 Self-assessment of health status, frailty, or
physical/mental functioning
 Biometric measures (when these data are not
readily available from laboratory results or
medical records): e.g., overweight and obesity
(height/weight, body mass index (BMI), waist
circumference), hypertension
(systolic/diastolic blood pressure), blood lipids
(HDL/LDL and total cholesterol, triglycerides),
and blood glucose (blood sugar and
hemoglobin A1c levels)
 Psychosocial risks: e.g., depression/life
satisfaction, stress/anger, loneliness/social
isolation, and pain/fatigue
 Behavioral risks: e.g., tobacco use, inadequate
physical activity, poor nutrition or diet, * Health risk assessments (HRAs), in conjunction with
excessive alcohol consumption, prescription follow-up counseling, coaching, and behavior change
drug use for nonmedical reasons, and motor interventions make up the personalized prevention plan,
vehicle safety aimed at improving the health and well-being of
 Compliance with current screenings, Medicare beneficiaries. This approach also applies to a
chemoprophylaxis, and immunization non-Medicare population, including privately insured
guidelines established by the USPSTF and ACIP adult individuals in both the individual and group
(when this information is not available from markets, when an HRA and follow-up interventions are
the EMR or PHR) used to promote health and prevent disease.

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What HAE Looks Like: Clinic-Based

Primary Care
Physician

Care Partner

Entrance

HAE

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Economics

 Roles Total PMPM
– Care Partners – Engage Revenue 8,175,000 11.35
enrollees and capture
assessment data
– Data Partners – Pre-populate Expenses Direct Labor Care Partners 4,200,000 5.83
assessments with available
data and ensure presentation Data Partners 840,000 1.17
of updated data to systems of-
record Management 1,414,000 1.96
– Management – Train and
Sub-Total 6,454,000 8.96
deploy Partners while
providing regular progress
Direct Non-
reviews with designated client Labor 312,000 0.43
leaders
 Size*
– One Care Partner / 1,000 Sub-Total 6,766,000 9.40
enrollees
– One Data Partner / 5,000 Contribution 1,409,000 1.96
enrollees Contribution
– One Manager / 15,000 Margin 17% 17%
enrollees
– One Program Director / 60,000
enrollees Enrollees 60,000

* fully operational program at 60,000 engagements and assessments annually

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Approach: Consultation to transfer

Enterprise Pilot Selection Pilot Evaluation
Program Launch
Evaluation and Launch & Program Design
 Know what current  Develop a pilot HAE  Conclude pilot or set  Commence program
and planned programs program proposal that an endpoint for pilot launch with 12-24
and services affect or is representative, evaluation month timetable to
will be affected by the replicable, run-rate.
implementation of  Review pilot
measurable, and
HAE performance, identify
bounded in time and
strengths and
cost
 Array populations, weaknesses
sites of service, and  Establish evaluative
potential HAE  Develop refined
criteria and
beneficiaries program proposal of
communications plan
appropriately larger
 Develop an HAE  Launch pilot scope
methodology, staffing
plan, and program  Review proposal with
management model program and client
incorporating the leadership
organization’s needs  Revise and ratify
and capacities Duration: 6 months program proposal
Duration: 6 months Duration: 6 months

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Agentic Health Leadership
 Denny Brennan – Denny has over two decades of experience as a consultant and entrepreneur working with the country’s
leading academic medical centers and medical schools, integrated delivery networks, hospitals, service providers, and industry
associations on strategy, organizational effectiveness, and information technology challenges . He brings specialized expertise in
population health management, healthcare policy, business strategy, and risk management to assist organizations in preparing
for success under increased market competition and health reform.
Denny earned a Masters of Human Development and Psychology from Harvard University and a Masters in Public and Private
Management from the Yale School of Management.

 Martin November, MD –An OB/GYN physician and was a member of the teaching faculty at Harvard Medical School for more
than 10 years. He held various administrative positions at the Beth Israel Deaconess Medical Center including Director of the
Division of Community Medicine. His academic research focused on patient safety, cost effectiveness analysis, and process
improvement in healthcare. He worked with researchers at the Harvard School of Public Health on The Malpractice Insurers’
Medical Error Prevention Study (MIMEPS), a nationwide study of malpractice claims and medical errors.
Prior to joining Agentic Health, Martin has worked with Advanced Practice Strategies and the Harvard Business School
Healthcare Initiative to develop the first Harvard Business School Health Science and Business Immersion Program in January
2006. He earned a Bachelor of Arts degree at Duke University, a Doctor of Medicine degree at the University of North Carolina
at Chapel Hill, and a Master of Business Administration degree at the Harvard Business School.

 Gary Gallant – Gary is an accomplished entrepreneur with 25+ years of technology sales, marketing and management
experience. His background includes founding, building, managing, consulting, mentoring and seed-funding multiple pre-launch
and early-stage software companies in a range of markets including information security, financial trading, mobile social
networking and healthcare informatics. He is a graduate of the University of Massachusetts, Lowell MA with a BS in Business
Management and currently serves as Chairman of the Board of Directors of a large, non-profit, inner city secondary school.

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Population Health for Accountable Care: A Parable

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