MemorialCare: Health System-Level Accountability for the Triple AimRegina Berman, VP, Population Health & Accountable Care

Helen Macfie, Chief Transformation Officer

C17, IHI Forum, December, 2017

Session GoalsPresenters have no conflicts to disclose

Focus: Creating a portfolio of population health initiatives across multiple payors and settings to pursue Triple Aim results.

Keys:• Macro and micro systems to successfully

deliver on ACOs and Bundled Payment• Drivers and learnings from five ACOs+

1. Galvanizing leadership2. Creating a strategic roadmap – & case study3. Advancing our overall “system of care”4. Innovating to improve care, quality & safety5. Governance6. Outcomes & 360 ROI thinking7. Where to next and questions

1 Galvanizing Leadership

About MemorialCare

Total Assets $3.3 billion– Annual Revenues $2.3 billion– Bond Rating AA- stable

Hospitals– Patient Discharges 67,000– Patient Days 317,000– ER Visits 214,000– Babies delivered 10,500– Surgeries – IP/OP 31,700

Ambulatory Access– “At Risk” Lives/ACOs 260,000– Seaside Health Plan 40,300– Medical Group Visits 600,000– Ambulatory Surgeries 57,000

Workforce– Employees 11,000– Affiliated Physicians 2,600– Employed Physicians 230

What made us go down this path?

STRATEGIC AIMRight thing to do

Shifting from Hospital-Based to Integrated System of Care

Strategic differentiator

Galvanizing leadership

BUILDING WILLShared learning• Deep Dives 2012, 2014Site visits, study teams• Capturing takeawaysLeadership Retreats• Triple AIM• “Big names”Planning for ambulatory diversification• Medical Foundation• Sites of careExecutive sponsors• Population Health• Clinical IntegrationContinuous messaging

2 Creating a Strategic Roadmap

Artistically speaking…

Strategic focus and evolution

Changing the mixPortfolio diversification

INTEGRATING DELIVERYMedical Group and IPA• 25 years of successful HMO experience• Now 914,000 active patients• Primary care chassis and specialist network• Partnerships – UC Irvine Health, Cedars Sinai, ACO partners

Ambulatory Services• Revenue diversification & strategic partnerships• Joint venture (ASCs, Imaging, Dialysis)And…ACOs R Us• 92,150 ACO lives• 260,000 total “at risk lives”, plus 50K in Health Plan and Vivity• Bold Goal 500K by 2021

Committing to risk-taking and the Triple Aim

ACO or At Risk Attribution and Key Descriptors

CMMINext Gen ACO

Boeing

What Employers Want

“If providers can’t give us lower cost, better outcomes and better quality, we don’t want to waste our time; we can get the current value anywhere.”

David Lansky, CEOPacific Business Group on Health

$VALUE = QUALITY

Boeing Preferred Partnerships

Rigorous RFP Process

ALL HANDS ON DECKDriven by MercerShort time frameRequirements

Boeing Selection CriteriaExquisite care and service

Network• Quality• Access Culture• Physician leadership• Readiness for change, collaborativeFinancial• Willingness to invest, take riskInfrastructure• Ability to support transformation• Strong provider management• Technology, systems

PROGRAM DESIGN• Mixed PPO Model

• Designated – Employee elects program during annual enrollment• Attributed – majority of care is delivered at ACO partner

• ACO network is ‘In-Network’• PCP encouraged, not required

Financial Incentives for Employees• Lower employee premiums• Higher company funded HSA• No cost PCP office visit• No cost generic drugs

HDHP

PPO

HMOs

HDHP

PPO

HDHP

PPO

HMO

ACO

2016 2017

Boeing ACO Plan Structure

Network Development & Partnerships

Overview

BOEING’s EXPECTATIONSCost Reduction• Key levers: care coordination, setting of care - freestanding, pharmacy spend

Population Health• Key levers: 3D care model, intensive outpatient & clinics, key quality measures

Patient Experience• Ease and access to EHR, appointments, triage, referrals (24/7 Nurse Advice and Rx

Refills, home visit, telemedicine)

• Dedicated microsite

Financial Terms

KEYS TO MODEL• Providers paid at existing PPO rates by Blue Cross Blue Shield of Illinois• ACO guarantees a reduction in Total Cost of Care for each Performance Year• Savings (or losses) are shared• Savings (or losses) are adjusted for hitting Quality, Patient Experience, and

Access benchmarks

Strategic Value

Supports Strategic PlanFirst-to-Market leaderBranding, market positioning

Business growth & retentionCatalyst for transformationACO portfolio & experience

3 Advancing our Overall System of Care

The larger opportunity

Source: RTI/Cain Brothers Analysis, “Integrating Acute and Post-Acute Care”, 2012

LTCH

IRF

SNF

HHA

OPT Th.

• Patient centered primary and specialty care

• Access based on patient needs (i.e. telehealth; same-day visits; e-visits)

• Special care coordination and chronic care management programs

• Patient Activation assessment

Seco

ndar

ydr

iver

sPrimary drivers

Objectives MemorialCare ACODriver Diagram

Beneficiary Experience and

Engagement

Provider Support and Engagement

InformationTechnology and Analytics

Care Delivery and Management

Act

iviti

es a

nd e

lem

ents

• Provider and Staff Education

• Reminders at the point of care in chart

• Incentives based on achievement of quality metrics

• Disease Registries• Beneficiary

Identification at the point of care

• Identification of Gaps in Care

• Data and Analytics Capability

• Effective Cost Analysis

• Predictive Modeling and Risk Stratification

• Physician/ Provider Care Teams

• Care Coordination• Transitions of Care• Discharge Planning • Medication

Reconciliation• Advanced Care

Planning• Advanced Care

Planning & Palliative Care

Improve the health of beneficiariesImprove their experience of care – quality, access,

and service; and reduce per capita costs

Ensure members receive the right care, at the right time, through advanced care

coordination and patient support services

Support providers to ensure quality; positive health outcomes; and efficient resource use through advanced technology and tools

Evolving the “3D Care Model”Resourcing the plan

Meet the ACO Team

Building a Core TeamManagement TeamProject ManagersCommunity Based TeamAnalystMid-Levels (home visits)Case ManagersCare CoordinatorsSocial Work Services

Leveraging the InfrastructureNetwork Management

ContractingQualityPharmacy

Imbedded Hospital Case Manager

Keys to InfrastructurePopulation Health “data” action

Investing WiselySimple actions workDaily huddles on admitted patients• Why here and what’s the plan?Virtual case conferences

Manage the high riskIntentional triage, navigation• Post-discharge clinics• Disease-specific (diabetics)• Intensive Outpatient Clinic

Population Health IT Tools BIG Data needed• Data repository• Data Analytics• Risk Stratification• Member Match

Ex: Risk Stratification

**No PHI used—not a real patient

Ex: Enhancing Point of Service Visibility across the continuum

4 Innovating to improve Care, Quality & Safety –Filling in the Cracks

Picking up the pace on BIG quality & safetyFilling in the Cracks

MULTIPLE CRACKS TO ADDRESS

SO MUCH OPPORTUNITYFURTHER TESTS of ∆:1. Go and see

2. Quality is everybody’s job

3. Support for care transitions

4. Office practice redesign

5. Flipped discharge innovation

6. Post-acute collaboration

7. Addressing overdiagnosis

8. AND don’t forget about EQUITY

PDSA #1: Before data, “go and see”

Go to GembaEngage Lean Thinking – horizontal and vertical at point of serviceBPCI Case Study: 9 pools, 9 ways, 4 phases• Preadmit/admit phase

• Operative/recovery phase

• Post-operative phase

• Discharge & transitional care

Care and flow redesign opportunities abound everywhere!• With opportunity to prioritize…

Sponsor check-in points

ACO Quality Metric Mania

Here’s just one example for Depression Screening (2016 measures):• Boeing (original def) – get credit if assess

within 1 month of PCP visit AND, if score high, meet the % target for depression remission within 6 months

• NextGen ACO – get credit if hit a different target for the % screened and then % in remission at 12 months

• Integrated Healthcare Association for CA Medical Groups/IPAs – 2017 to measure % assessed within defined 4 month measurement period, no target yet

>100

PDSA #2: Quality, Its Everyone’s JobEvolving the care team – addressing quality metric mania

LEVERAGING LEAN & ADVOCACYGoing offline to make a difference, needs supportNon-value-added “waste”Building in safetyHarnessing best ideasTests of change by MondayCreating standard workTools and tip sheetsRedesigning roles• Doctors, nurses, MAs, front officeBuilding into visibilityHuddles and dataChanging cultureAdvocacy for harmonizationIt’s working!

PDSA #3: Model of Care TransitionsFostering the accountable in ACO

SAFER TRANSITIONSColeman model• Use of a transition coach• Teaching skills, knowledge and attitude to empower and

manage to remain healthy & functionalThe 4 Pillars1. Medication self-management2. Patient-centered health record3. Timely follow-up with primary and specialty care4. Knowledge of red flagsDischarge PharmacistPatient contacts 30/60/90/180 days• Hospital/SNF Visit• Home Visit• Telephone Calls

The issue:• Inadequate preparation

for the next setting of care

• Patients/family act as default care coordinators

• Which leads to med errors, postponed follow-up care and re-hospitalization

• Re-hospitalization reduces value – Q/C

PDSA #4: Office Practice RedesignInnovating in a Value Stream

INNOVATING PRIMARY CAREInnovation Value StreamMultiple tests & spread• Office flow redesign• Ease & access• Communication throughout• Increased time with patient• Group visit redesign – chronic disease management• Roles team-based care

Patients love it!

PDSA #5: Flipped DischargeEnsuring safe transitions

DISCHARGE IN THE HOMEInnovation Testing• CWF/IHI global sourcing• Segmentation• D.R.I.V.E. team• LACE scoring• Ongoing PDSAs

PDSA #6: Post Acute Care FacilitiesBuilding coalitions, solving together

KEYS TO PARTNERSHIPCreate a VisionShared commitments• Share best practices/knowledge• Mentor partners & providers• Share data & support analyses• Promote implementation of evidence-based

interventions• Regular meetings, decision makers have to be present

The Community Coalition to Enhance Care Transitions (CCECT) is a leader in

establishing and initiating best practices to ensure safe and effective care transitions

for patients across the health care continuum

Post Acute Coalition Key Programmatic Changes

Improved Outcomes

Acute Hospital NPs share

learning/coach at SNF site

VP of Pop Health came to share learning about ACOs &

Bundled Payment

Weekly calls between CM and SNF with

High Risk readmit patients

MC Link to share

documentsEducational

opportunities to strengthen assessment

skills for both RNs & CNAs

Create Transfer form: to & from

SNF-ED

SNFologistprogram for

ensuring alignment with hospital/ACO

goals

Standardize RN to RN handoff

PDSA #7: Addressing Overdiagnosis head-onWe are stewards of precious resources

OVERDIAGNOSIS & OVERTREATMENTThe diagnosis of a condition or abnormality which will, if left alone, never cause symptoms, complications, or shortened life

The Prescription:• Make it strategic, hosting broad discussions• Understanding NNTB/NNTH and POEMS• Smart alerts – wisely choosing wisely• Shared decision-making – TheNNT.com• Advocacy – P4P measures that promote overtreatment• Addressing publication bias – publicizing ALL research

Opportunity to override per indication (evidence-links). Active learning over time greater impact than % followed

How to Overdiagnose1. First, change the rules

2. Improve technologies to see more3. Look harder4. Stumble onto incidental findings

Condition/Threshold

Old Definition

New Definition

New Cases Resulting

% Number Needed to Treat to Benefit

Number Needed to Treat to Harm

Diabetes – Fasting BG 140 126

11,697,000 13,378,000 1,681,000 14% ∞ (Death, MI, CVA, RF)250 (Prevent limb loss)

6 (hypoglycemia w/ hospitalization (1)

HypertensionSBP 160 140DBP 100 90

38,690,000 52,180,000 13,490,000 33% ∞ 12 (2)

HyperlipidemiaCholesterol 240 200

49,480,000 92,197,000 42,647,000 86% 50 (MI); death 244 5-20 (myalgia, weakness, cognition, DM) (3)

Osteoporosis in WomenT Score 2.52.0

8,010,000 14,791,000 6,781,000 85% ∞ ~500? (4)

Prediabetes 0 52,000,000 52,000,000 ∞ 4-8 Lifestyle change14 (metformin) (5)

2.4 (6)

1. www.TheNNT.com2. Redberg R, JAMA Int Med 11.13.20163. www.TheNNT.comn4. Gruber A et al., Int J Clin Pract 2006;60(5):5905. Drug Facts and Comparisons Oct. 2004

PDSA #8: EquityBuilding a Community focus

Social Determinants of Health and Life

Focus on equity2017 Physician Academy project teamCollaboration with Long Beach Health & Human ServicesInconvenient truths

• Household wealth• Social status• Support networks• Education• Employment• Social environments• Physical environments• Personal health

practices & coping skills

• Healthy child development

• Gender• Culture

Inconvenient truthsSDOH Impact in Long Beach, California

6 Governance

Our organization today

ACO requirements for oversight

Not one size fits all• Each ACO requires its own structure

• Ex: NextGen – Board of Managers, 80% practicing providers from roster, beneficiary and advocate

• Partner relationships and representation

Executive Steering teamStrategic Plan, annual review

Driver Diagram Metrics - customizable

Secondary Driver Metric (Data Source)

Member Experience and Engagement

• Increased In-Network Utilization (claims)• Patient Activation Assessment• Satisfaction Survey (CG-CAHPS)• Reduced ER utilization (claims)

Care Delivery and Coordination

• Reduction in ambulatory-sensitive admissions; reduced readmissions (claims)• Percent of discharged patients with medication reconciliation (quality data)• Percent of beneficiaries with evidence of Advanced Care Planning• Reduced SNF days per 1,000 (claims)• Increased generic prescribing rate (claims and chart)

Provider Support and Engagement

• Quality Metrics achievement (quality data)• Increased utilization of efficient providers or services (claims)• Provider satisfaction (survey)• Increased ASC utilization (claims)

Information Technology and Analytics

• Deploy analytics solution to include risk stratification; targeted interventions; integration with EMR; and ability to identify beneficiaries at point of care (in-house measurement)

7 Outcomes & ROI Thinking

Achieving Triple Aim ImpactStories matter – high touch care, building trust

BackgroundDW is a 69 y/o Latina female who had 21 ER visits in the last year, 17 resulting in admission

Major diagnoses: Diabetes Mellitus (DM), newly Dx Liver CA, cirrhosis, GERD, and depression

Social history: widow, with 3 minimally involved sons

ACO Case Management Intervention• Outreach to PCP and creation of a comprehensive plan of care• Mid Sept initiated daily calls which helped her safely manage at home• Social Work helped move her to an Extended Stay with her cherished

pet • Purchased and delivered a holiday meal using Memorial Care "Simply

Better" funds as she knew DW would be alone for the holiday• ACO Services: Care Coordinator, Case Manager, NP for home visit and

Social Worker

Ongoing Progress & Outcomes• Facilitated move to assisted living facility

(with cherished pet) in Dec which reduced her living expenses by $800 per month, improved dietary options and DM management with facility administering medications

• Enhanced social interaction resulting in lifted spirits and improved desire to self manage care

• Reduced ED visits and admissions• Reduced the cost of care and significantly

improved the patient’s social supports and quality

UNDERSTANDING WHAT MATTERS TO HER

NGACO PerformanceThe deferred ROI, and actuarials really matter

2016 Performance year 1• 24,764 initial alignment• 18,988 year end = 7% change• Over 1000 providers, many specialists

2017 Performance year 2• 17,177 initial alignment• 13,749 estimated year end• 374 providers mostly PCP – 67 % reduction

Actual Raw Claims Costs (does not include risk or stop loss factors)

$1,032 $1,026

$870

$600

$700

$800

$900

$1,000

$1,100

CY 2015 CY 2016 CY 2017 TD

ACO Expenditure PBPM - AD

AD Linear (AD)

$8,466

$7,801 $7,716

$6,000

$7,000

$8,000

$9,000

CY 2015 CY 2016 CY 2017 TD

ACO Expenditure PBPM - ESRD

ESRD Linear (ESRD)

BPCI PerformanceMaking a difference in Episodic Care, sharing savings

100 %$25,000.

$26,000.

$27,000.

$28,000.

$29,000.

$30,000.

$31,000.

$32,000.

2015 Q3 2015 Q4 2016 Q1 2016 Q2 2016 Q3 2016 Q4 2017 Q1 2017 Q2

BPCI Average 90-Day Claims c/w Target PriceRoll-up: Ortho, PCI, CABG

Average MemorialCare Winsorized Episode Cost Estimated Target Price*

Drilling down on outcomes that matterCare redesign and focus on value works

30 day Readmissions:All Cause, All Payer

Total Cost of Care:Reducing PMPM $

ED Visits:Innovation Center Focus

Screening & Immunizations:Team-Based Impact

Medication Management:Discharge Clinic Interventions

Patient Ratings:Satisfaction with staff

Measure MCMG Score Irvine Score Breast Cancer Screening 72.4% 77% Colorectal Cancer Screening 59.5% 69.1% Nephropathy Screening 64.4% 71.8% Adolescent Immunizations 27.6% 41.1% Childhood Immunizations 50% 67.7% Chlamydia Screening 46% 62%

MedicationDiscrepancy

73%

Drug-Disease 5%

Duplication/Omission 5%

Drug-Drug Interaction 15%

More employers choosing usIf you build it, they will come…

Aetna Whole Health New for January 2018

Vivity – January 2015

Boeing – January 2017

Adventist – January 2017, 2018

Aetna Whole Health – September 2016MemorialCare-GNP network differentiation and growing reputation as the provider committed to value resulted in additional sold cases for 1-1-2018 go-live

Employers in the Queue

8 Where to Next and Questions

Barriers & Lessons Learned

KEY LESSONS LEARNED1. It is a strategic investment2. Engage actuarial assistance3. Partnering with others4. Outreach, explain, make it easy5. Patient centric support, involve6. Don’t budget return in year 1!7. Narrow networks Designated8. Engage expert resources, early9. Building & improving new tools10. It takes a village (IT, HR)11. Advocate for Q harmonization12. Focus on social determinants13. Leverage interest, collaboratives14. Education on # needed to treat15. Visibility, streamline, celebrate

Find the halo

POTENTIAL BARRIERS1. Leadership and vision2. Predicting risk and price of entry3. Geography4. Physician participation5. Patient engagement6. Focus on a performance year7. Attribution modeling8. Delayed / incomplete claims9. Data, data, data10. Adding (and finding) expertise11. Varying quality metrics12. Population segmentation13. Post-Acute alignment14. Overtreatment, overdiagnosis15. Equal opportunity burnout

Focusing only on ROI

Thank you.