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NCSL Winnable BattlesNCSL Winnable Battles

Harry ReynoldsIBMJune 6, 2011

Market forces require a new approach for the health care industry

Health care is shifting from local to national and global contexts

Empowered consumers expect better value, quality, and outcomes

Incidence and cost of chronic and re-emerging infectious diseases are increasing

Changing demographics and lifestyles drive associated costs

Industry Challenges

and Opportunities

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Primary Care and Nursing shortages demand workforce productivity and efficiency

New market entrants and new approaches to health and care delivery increase complexity and competition

Costs are growing for new, revolutionary technologies and treatments

Source: IBM HCLS, IBM GBS Institute for Business Value

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Trends, Reactions, Assumptions in the U.S.

Provider consolidation is acceleratingMedical Homes are in demandACO’s are evolving and re-defining partnershipsCompetitors are merging, payers/providers are mergingNew places and types of care are on the increaseQuality is required for both processes and outcomesProviders will know and market their quality and outcomesConsumer health will be the mantraPBMs, Labs, Pharmacies, and Retail Sites are engaging aggressivelyHospitals are evaluating a revenue shift to coordinated care

The tools available as you approach Winnable Battles

Global and national best practices at your local sites

Tools to Empower Populations before, during and after treatments

Technologies and information to reduce readmissions and hospital infections

Analytic capabilities to address the varied demographics and life service preferences

treatments

Realistic opportunities

to make a difference

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Benefits, care models, processes and information specific to the person and disease

New partners and best practices from health care and other industries

Access to new technologies to allow lesser cost venues to be prevalent and more patient-centric

Source: IBM HCLS, IBM GBS Institute for Business Value

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…IBM Employee Health Impacts

ABSENTEEISMABSENTEEISM

Short term Short term disabilitydisability

Long term Long term disabilitydisability

Unplanned Unplanned vacationvacation

PRESENTEEISMPRESENTEEISM

CognitionCognitionDistractionDistractionInterruptionInterruptionEngagementEngagementResilienceResilienceFlexibilityFlexibility

Medical claimsMedical claimsPharmacy claimsPharmacy claims

Behavioral Behavioral healthhealthCare Care

HEALTH CARE HEALTH CARE COSTSCOSTS

© 2010 IBM Corporation

vacationvacationDependent careDependent care

FlexibilityFlexibilitymanagement management

costscostsAdmin. costsAdmin. costs

Health Care trend is 53% Lower over 2004 – 2009 than in 2000 – 2003

Changed Subsidy Approach

Changed Health Plan StrategyIBM Net Health Care Trend Over Time13.3%14.0%

IBM Value and AffordabilityJourney

Changed Purchasing Strategy: best in market discounts/ administrative fees

Attacked Population Health: to stem pipeline of risk

•Reduced percentage of employees with high health risks by 55%

Over 80,000 IBMers are

9.3%

10.8%

3 3%

2.7%

6.8%

3.1%

4.3%

3.2% 3.1%4.0%

6.0%

8.0%

10.0%

12.0%

Average Trend During 2000-2003 is 8.5% per year

Average Trend During 2004-2009 is 4.2% per year

4.8%

© 2011 IBM Corporation

physically active

New Metrics to drive decision making and smart consumption: e.g. generic utilization increases to 96% voluntarily

0.0%

2.0%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Source for benchmarks: Average of survey results from Kaiser Family Foundation, Hewitt Associates, and Towers Perrin

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Payers/Providers have many initiatives underway, but will the health consumer buy in and engage in their own health?

HIE

© 2010 IBM Corporation

Reimbursementmodels

Accountable CareOrganization

High ValueCare

QualityOutcomes

New DeliveryModels

MeaningfulUse

Medical Home

HIE

More to Come…

Initiating the personalization of careAsthma is one of the diagnoses included typically included in Disease Management programs. In a commercial product, it is typically the program with the largest patient load (close to 15% of eligible members). The diagnoses on the right, in red font, are more specific asthma diagnoses that will allow Plans to develop targeted programs, stratify members more effectively, and reduce the occurrence of false positives.

Asthma – ICD-9 CM• Extrinsic vs. intrinsic• Chronic obstructive asthma• With status asthmaticus• With exacerbation• Exercise induced

Asthma – ICD-10 CM• Mild intermittent• Mild persistent• Moderate persistent• Severe persistent• With status asthmaticus• With exacerbation

© 2010 IBM Corporation88

bronchospasm• Cough variant asthma

• Exercise induced bronchospasm

• Cough variant asthma• Excludes chronic obstructive

asthma

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DIABETES

ICD‐9‐CM• 22 codes to report Diabetes 

ICD‐10‐CM• 318 codes to report Diabetes 

• Takes multiple codes to report the diabetes and any associated manifestations  of the disease.

• The reason for the large number of codes in ICD‐10‐CM: – combines the diabetes & the 

multiple diabetes manifestations into a single code & can even define and capture the use of insulin with a code

• Allowing for a more clinically 

LFord ConsultingLFord ConsultingSource:  NCHIMA

North Carolina Health Information Management Association

g ycomplete description of the codes reported

OBESITY

ICD‐9‐CM ICD‐10‐CM

• Three codes representing obesity– Unspecified– Morbid– Overweight

• Seven codes representing obesity– Morbid due to excess 

calories– Drug‐induced obesity– Morbid with alveolar 

LFord ConsultingLFord ConsultingSource:  NCHIMA

North Carolina Health Information Management AssociationLFord Consultimg

hypoventilation– Overweight– Other & unspecified 

obesity

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CONGESTIVE HEART FAILURE

ICD‐9‐CM ICD‐10‐CM

• 15 different codes representing heart failure and the type of failure

• 50 different codes and code combinations depending on the type of heart failure,  reflecting a more li i ll ifi fil

LFord ConsultingLFord ConsultingSource:  NCHIMA

North Carolina Health Information Management AssociationLFord Consultimg

clinically specific profile  of the heart failure

PATIENT NONCOMPLIANCEICD‐9‐CM

Currently only reported as one code:

V15 81 Noncompliance with medical treatment

ICD‐10‐CMExpanded to 8 codes:

– Z91.11 Patient's noncompliance with dietary regimen 

– V15.81  Noncompliance with medical treatment – Z91.120 Patient's intentional underdosing of medication regimen due to financial hardship 

– Z91.128 Patient's intentional underdosing of medication regimen for other reason 

– Z91.130 Patient's unintentional underdosing of medication regimen due to age‐related debility 

– Z91.138 Patient's unintentional underdosing of medication regimen for other reason

LFord Consultimg

LFord ConsultingSource:  NCHIMANorth Carolina Health Information Managemetn Associaiton

LFord Consultimg

other reason – Z91.14 Patient's other noncompliance 

with medication regimen – Z91.15 Patient's noncompliance with 

renal dialysis – Z91.19 Patient's noncompliance with 

other medical treatment and regimen 

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Member 360 – Adjusting the PerspectiveAm I getting the most

for my spend? Who canhelp me make better care

choices?

What’s the overall health of my organization?

What Wellness/fitness programs

are most effective?

What is the success of myWhat new products/

How do I compare with my peers?Am I rewarded forquality?

© 2011 IBM Corporation13 Demandsystem

Diabetes Mgmt Program?What about my Smoke Cessation Program?

How fast am I recognizing and acting on high cost cases?

What are my healthcare costs? Who are my high utilizers?

What new products/programs can I introduce? What value-add services?

Considering your population by segment?

• Which channels of information are the most effective for engaging different segments?• Which segments can Winnable Battles influence the most?• Which segments will provide the most positive impact?

H l k th i f ti t l d b fit ?• How personal can you make the care, information, tools and benefits?

© 2011 IBM CorporationNote: Bubble size is illustrative and not to scale. The conditions included in this figure as examples represent only a subset of the overall size of the segment.

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BreakawayPassionate sponsor 

of analytics

Analytics embraced &  integrated into every day decisions & operations

Communication & Culture

Test and Learn

Analytics Maturity LandscapeAre you aligning your information?

Performance Performance MetricsMetrics

Advanced Advanced AnalyticsAnalytics

IntelligentIntelligent

Predictive modeling

d

Leverage cross‐departmental & 

functional data to derive actionable 

insight

Performance messages widely communicated

Single version

Operational buy‐in to  performance analysis 

driving decisionsRobust feedback loop

p

Monitoring, Prediction, Action

Automated analysis/alert

Culture

DRAFT

BasicBasic

Descriptive Descriptive AnalyticsAnalytics

Pride in the gut based decision

Significant manual input

Contextual business 

rulesData warehouses, governance and production reporting

Isolated reporting & analysis systems

Integrated information 

Single version of truth

Personalized & role based 

portal

Collaboration & workflow tools to aid planning & info sharing

Leverage structured & unstructured 

data for decision making

Real‐Time Decision Support

Spreadsheets

Adaptive Machine Learning

Decision support systems for collaborative care

Outcome Measure: HbA1C Level

prototypes

Patient Similarity Assessment

Outcome Measure: HbA1C Level• Positive Outcome• Negative Outcome (blue)

Optimal Physician Prediction

Physician Outcome Modeling

© 2011 IBM Corporation16

? ??

Patient

Physician

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There is a proliferation of digital devices that captures data and is (or will be) connected

WeightScale

Health Care devices as an extension of care! Cholesterol Monitor

The current state of health devices

Thermometer

GlucoseMeter

Blood-pressure

Scale

PulseOximeter

Spirometer

How do they affect health outcomes?Are they included in your benefits?Who coordinates the information?Can they be a key inclusion in:

“Winnable Battles”?

Homesensing &

control

Bed / ChairSensors

ImplantMonitors

© 2011 IBM Corporation

Pedometer

MedicationTracking

Fitnessequipment

Spirometer BabyMonitors

PERS

ConsumerElectronics

Sources: WHO definitions; IBM Institute for Business Value Analysis

What is a SmartRoom?A “smart” patient room that…

– Organizes the workflow of front-line staff to simplify and improve the quality and safety of care giving

– Makes retrieving the right patient information at the right time as simple as walking into the room

– Enhances the documentation of patient information in the patient’s room and the nurse’s station

– Engages the patient and their family through improved communication, education and entertainment

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Health Benefits to Consider for Specific Diseases

Transportation

Drug co-pay waivers

Home devices

Case thinking for specific diseases

Monitoring in retail settings

Home visits

Nurse coordinators for discharge handoffs and patient transition

Pharmacist consultationsPharmacist consultations

Health Risk assessments with incentives and personalized (50%)

Personalizing Care, benefits and outcomes

Diagnosis- (ICD10)

Care Models by diagnosis

Quality based on diagnosis and meaningful use

Outcome analytics and similar patients

Benefits flex by diagnosis and personal characteristics of each patient

Care settings are varied and local (neighborhood or aligned providers)

Monitoring is personal and uses preferred technology

© 2010 IBM Corporation

Monitoring is personal and uses preferred technology

Patient buy-in is requested, recommended and required

Primary care is a foundation that is enthusiastically embraced

Disease maintenance is inherent and personalized

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The Call to “Winnable Battles”

Exciting approachNever a better timeNever a better time

Never more care models and technologies availableCurrent approaches are lacking

Each of you is affectedEach of you is defining a real approach and an answer

The industry is ready to assistWhat a great legacy to create