Embed Size (px)
Citation preview
National Healthcare Innovation Summit
“Health Systems as Insurers – Innovations that Bend the Trend”
June 11, 2013
Our panelists
2
Seth FrazierChief Transformation Officer, Evolent, Arlington, VA
Michael DermerPresident and Chief Executive Officer, IncentOne, Lyndehurst, NJ
Samuel Skootsky, MDChief Medical Officer, UCLA Medical Group, Los Angeles, CA
June Simmons, MSWPresident and Chief Executive Officer, Partners in Care Foundation, San Fernando, CA
Eric Jensen, ModeratorChief Operating Officer, Avia, Chicago, IL
Confidential – Do Not Distribute
Evolent Health: National Healthcare Innovation Summit “Health Systems as Insurers – Innovations that Bend the Trend”Seth Frazier, Chief Transformation OfficerJune 11th, 2013
Confidential – Do Not Distribute
Evolent’s Comprehensive Population Health and Health Plan Infrastructure
4
Offerings
Payer-Neutral Population Platform
Health System Employees
Medicare Advantage/ACO
Commercial Payers
Managed Medicaid
Commercial Health Plan
I. Strategic “Blueprint”
(i.e., integrated value-based business plan)
II. MSO
Population Management & Network
Health Plan
Analytics & Workflow Engine
Providing the People, Process, and Technology to Assist Health Systems in the Movement to Value-Based Care
(UPMC and Advisory Board Launched Company)
Confidential – Do Not Distribute
UPMC Case Study: Population Health Outcomes
5
Superior patient engagement…2010 - Indexed to 1.0
Admin Costs as % of Revenue
“Highest Member Satisfaction “in 2011
“Excellent” for HMO, POS, Medicaid HMO, and MA
MyHealth programs recognized for excellence
in health and wellness
JD PowersNCQANational BusinessGroup on Health
…and earning top marks for health plan qualityAchieving outcomes at scale…
…leads to lower trendEmployee 2011 trend
Compounding Effect of Lowering TrendPMPM Trend: UPMC vs. Industry
$65,732,231 5-year savings $65,732,231
5-year savings
$4.5M $6.9M $3.3M $15.4M $35. 6MSavings by Year
Demonstrated Mastery of Population Health
“Best Customer Experience Award” 2013
International Customer Mgmt Institute
Industry Average
UPMC
Confidential – Do Not Distribute
Technology Overview
6
Evolent employs a locally staffed model to embed professionals to complement a system- wide care team
Commercial HMOManaged Medicaid Plan
Labs
PBM RxPrimary Care / PCMH Un-Owned Group PracticesHospitals
Patients
Social ServicesHome Health
Skilled Nursing Facilites
Medicare AdvantageEmployee Health Plan
HIE
Biometrics
Care Team Inputs
Rules Engine and Workflow Layer
Integrated Reporting and Dashboarding Layer
Identifi Platform Supports an Ecosystem of Care
Confidential – Do Not Distribute
Population Health
Core Principles of the Evolent Population Health Model
7
PARTNERING WITH PAYERS TO
ALIGN INCENTIVES
RECONSTRUCTING THE CARE MODEL
ALIGNING PHYSICIANS WITH A VALUE-BASED PAYMENT MODEL
PROVIDING QUALITY- DRIVEN CLINICAL
PROGRAMS
ENGAGING PATIENTS WITH A PROACTIVE TEAM
TRANSFORMING DATA INTO ACTION
MANAGING TOTAL COST OF CARE
Confidential – Do Not Distribute
UPMC PCMH Practices Experienced Significant Improvements in Cost and Utilization
All differences statistically significant with p < 0.01
7%
7%
4%
28%
10%
5%
PCMH Rest-of-NetworkCost
Utilization
Total cost of care Medical costs Pharmacy costs
Inpatient admissions Readmissions ED visits
8
Confidential – Do Not Distribute 9
Historical Benefit Trend New Platform (Began Jan 2012)
• Historical trend includes medical and pharmacy claims • New platform includes medical claims, pharmacy claims, administrative fees, but does not include ACA fees• Savings compared to calendar year 2012 claims and fees as the baseline• In-system utilization improvement of 12% over 3 years through shift to Tier 1 in CareFirst PPO and MedStar Select use (49% to 61%)
Estimated2013
To DateJuly 2012 -June 2013
2.3%
6.8%6.0%
Rolling 1 Year 2012
(excluding unit price impact)
8.1%
Rolling 2 Year2010-2012
7.1%
Rolling 5 Year2008 - 2012
Bottom Line Impact (Before Gainshare)
$9M
Baseline
CY benefit plan savings (vs. 6.8% trend)
In-system utilization improvement (contribution margin)
2013 Estimated
2014 - 2015 Estimated
$30M
$25M
$6M
Key Current Sources of Savings:•PBM•UM•Benefit Design
Key Future Sources of Savings:•Primary Care Redesign
Total Bottom Line Impact (Before Gainshare):
•2013 Estimated: $15.3M•2014-2015 Estimated: $54.9M•2013-2015 Estimated: $70.2M
Employee Plan Early Highlights the Benefits of Integrated Platform
Incentive Driven Healthcare™Incentives and The Triple AIM
Michael DermerCEO/President
IncentOneJune 11, 2013
Incentive Driven Healthcare™ (IDH) is the next movement in healthcare
IncentOne reduces healthcare costs by providing an engagement engine
to change consumer and provider behavior using incentives.
What does IncentOne do?
11
CONSUMER ENGAGEMENT
PROVIDER ENGAGEMENT
Experience of the ”First Mover”
12
Unparalleled experience:
• 1st company 100% healthcare
• Launched 1st program in 2005
• 8 years of actual program data
• 36 million transactions
• Unique operational experience
• Known brand
Item 2012
Health Incentive Transactions 36M
Health Milestones 27M
Self-Reported Activities 13M
Unique Programs 3,500
Data Integration Relationships 130
Members Accounts 6.9M
Data Integration Relationships 130
Eligibility Files Processed 7,955
Rewards Processed 1.5M
Activity Files Processed 20,630
Information Security Reviews 130
Is engagement via incentives one health service or the “hub” to drive effectiveness of all health services?
Incentives as Key Driver of Engagement
13
Incentives have emerged as the most important tool to reduce cost:
Why incentives?
14
Incentive Driven Healthcare™ (IDH) is the next great wave in healthcare
Philosophy – Incentive Driven Healthcare™
The key to reducing cost is changing consumer and provider behavior:
Incentives drive key actions as part of strategies:
Obamacare Value Based Benefits Payment Reform
Medicaid Reform Consumerism ACO
Medical Home Med. Adherence Pay for Performance
Utilization Telehealth Provider Quality
Patient Safety Medical Tourism E-Prescribing/EMR
Never Events Social Media Five Star Ratings
CONSUMER ENGAGEMENT PROVIDER ENGAGEMENT
15
Goal = Proactive Personalized Interventions:
Personalized, Proactive Intelligence
16
Every health service provider will have a Chief Incentive Officer
who will oversee the deployment of incentives in all patient and provider programs
The Future
17
18
Samuel A. Skootsky, M.D.Chief Medical Officer, UCLA Faculty Practice Group and Medical Group
National Healthcare Innovation SummitJune 11, 2013
UCLA Health
• UCLA Faculty Practice Group– 1200+ physicians, 200 primary care– Risk bearing & ACO components
• UCLA Medical Group– Contracting entity for PPO, etc.– Partial and Global Risk Contracts
• Commercial and Medicare Advantage HMO
• UCLA Hospital System– Acute, Psychiatric, Children– Partner in ACO and Risk Contracts
• David Geffen School of Medicine
Our Approach Embraces “System” Attributes…
20
UCLA Health System
Primary
Care Base
Primary
Care Base
UCLA Primary Care
• Our vision is a systemic change in UCLA Health– Extends beyond “medical home”– Requires collaboration and support from other
components of UCLA Health System
• Care coordination a central feature• Triple Aim (better health, better healthcare,
lower or attenuated risk adjusted per capita cost)
• Maintaining the primary care workforce
21
Objectives Codified UCLA Primary Care Innovation Model (PCIM)
I.
Implement Practice Re‐DesignI.
Primary Care Re‐designII.
Related “System”
Re‐design
II.
Increase Covered Lives Under UCLA Population ManagementI.
“UCLA as an ACO”‐
Seeking collaborations that support payment reformII.
Geographic Expansion
III.
Expand Primary Care System CapabilitiesI.
Pre‐primary Care, retails clinics, telemedicine
IV.
CollaborationI.
Internally & Externally
V.
ReplicationI.
Internally & Externally
VI.
Evaluation 2222
“System”
Support: EHR, Data aggregation, Population Registries, Predictive Modeling, Decision Support , Practice Standards,
Quality Measurement and Reporting, Accountability, Tele‐Medicine, Tele‐Health
Patient‐
Centered
Shared Decision
Making
Traditional
Benefit‐Based
Home Health
Hospital & Hospitalist‐
Extensivist Programs
CommunicationCare TransitionsER interventions
Efficient hospital use
SNFist and
SNF
Program
Ensuring Care Implementation in the
Community & at Home•Home Palliative & Hospice
•Home Social/Environmental Factors •Patient Coaching
•Transitions of Care •Use of Community Resources•Comprehensive Care Centers
Optimal
Discharge/Transitions
23
Overall UCLA Population Management Plan
Updated Mar 2013
PCMH Practice &PCMH Practice & Health System ReHealth System Re‐‐DesignDesign
UCLA Health System
Primary Care PracticeTeam Care
In‐home services In‐home services
Physician &MA‐LVNsOther staff
Home palliative careHome palliative care
PCIM Effect: UCLA Facility Use
Number of
patients in
cohort
Trend in rate
(mean 7 months
observation after
intervention)
Emergency Department
Use 1093 ‐29%
Acute Care Hospital Use 1093 ‐19%
Preliminary observation results as of February 2013, based upon 14 PCMH
offices, 1093 patients with 12 months baseline data and at least
6 months
(mean 7 months) of observation after care coordinator/PCIM interventions.
UCLA Transformation Method
Design/ Implement/ Operationalize
For Accelerated Replication and Scalability
26
1.
Define High Level
Project Objectives
2.
Executive Chartering3.
Propose Quick Hits that
consider priorities
4.
Define Design Team
Charge
5.
Propose metrics for
success
1.
Design an initial model
approach to accelerate
the implementation
and sustainability of the
objectives
2.
Define implementation
teams as needed
3.
Adapt and expand
model over time
1.
Implements one or
more specific
applications to achieve
objectives.
2.
Refine and expand
applications
3.
With local adaptation,
spread across the
system
1.
Apply principles of
Implementation
Sciences and Health
Services Research
2.
Seek to define the
success factors.
3.
Further refinement of
metrics and model
Articulating the Vision, Repetition, External ReferenceArticulating the Vision, Repetition, External Reference
Care Coordinator Innovation
• Requirements set by Design Team• Required new job description• Unlicensed care coordinator 1:1 with physicians &
practice• Centralized training and active management• Licensed Advisors as needed• Utilizes registries, active daily reports, case
management tracking• High rates of provider and patients satisfaction• Care Coordinator panel = the practice panel
28
Wellness Programs HRA & Biometric Screen,“person journey”
Engagement
Platform
Employee Patient
Employmen
t Realm
Med
ical care Realm
Provider‐Employer Innovation: UCLA Care
Whole Population Health Management
Total Population
Unknown RiskNo Risk Known Risks
March 2013
Absent intervention, a sub‐population become “patients”…
those who seek
medical care on their own for preventive services or due to clinical
symptoms or complications.
UCLA Care Prevention Plan
30
Study Cohort Individual Risk Reductions (after 1 Year on Plan)
YEAR 1
Loeppke, R; Edington, D; Beg, S. “Impact of The Prevention Plan on Employee Health
Risk Reduction.”
Population Health Management. 2010 13 (5): 275‐284
March 2013
UCLA Care will focus on Individual Risk Factor Reduction
Provider‐Employer Innovation: UCLA Care
Health Coaching/Entry point to Care
Coordination
“Triple Aim”&
Maintained
Primary Care
Workforce
HRA, Health &
Biometric
Screenings& Risk Assessment
Medical Home/
Establish PCP
System/ EHR
Chronic ConditionManagement
Pharma Utilization &
Formulary
Compliance
Choose a
Primary Care
Provider
31
UCLA Health System
Primary
Care
Base
1. Primary Care Providers focus
on risk reduction.2. PCIM is a gateway for care
coordination and preventive
services, and some acute and
chronic illness services.3. Role of the specialist is to
provide expert clinical care of
high value.
Provider‐Employer Innovation: UCLA Care
UCLA Primary Care Innovation Model
Primary Care and Related System Re‐Design
Summary as of May 2012‐June 2013
• Implementation/Engagement
– Monthly Leadership & Design Team meetings
– Quarterly Retreats
• In Office Re‐Design:
– PCMH/Team based care (huddles, meetings, etc.)
– Embedded Care Coordinators (unlicensed)
– Embedded Pharm D (My Meds)
– Populations defined
• FPG & System
– Director of Care Coordination & Population Health
1:14
– RN Clinical Advisor Case Manager
– LCSW Case Manager
– “Patient Care Coordination System”
– Behavioral Health Expansion in primary care offices
– Transitions Management – hospitalist program ,
post‐acute care transitions, ED components
– Care Connect‐EHR
– Patient Portal – “MyUCLAHealth”
• Registries & Measurement
– Patient Panels
– Utilization and care gaps
– Registries (e.g. Diabetes, Patient panels, P4P care
gaps)
– Risk model strategy
– Provider Survey
– Patient Experience Survey (CG‐CAHPS)
• Expansion of primary care system capabilities
– Urgent Care
– Retail Clinics
– Home care (planned)
– Telemedicine Pilots
• Internal replication ( to 14 offices after 6 months)
• Employee Population Engagement (Pilot)• Health Risk Assessment & Biometric screen• Health coach‐navigator & PCP initial visit
Q & A
Samuel A. Skootsky, MD, FACP
Chief Medical Officer
UCLA Faculty Practice group and Medical
Group
UCLA Health
Office 310‐794‐8883
FAX 310‐206‐7975
Email [email protected]
Health Systems as Insurers – Innovations that Bend the Trend June Simmons, CEONational Healthcare Innovation SummitJune 11, 2013
Partners in Care Who We Are
Partners in Care is a transforming presence, an innovator and an advocate to shape the future of health care
We address social and environmental determinants of health to broaden the impact of medicine
We have a two-fold approach: evidence-based models for practice change and for enhanced self-management
Changing the shape of health care through new community partnerships and innovations
Active Patient Population Management
Three-way partnership for whole person care
MedicineMedical Groups
Hospitals Health Plans Home Health
Skilled Nursing Facilities
PatientsEmpowerment
Through Education
Community-Based Services
Health Self-ManagementIn-Home Care Coordination
and Coaching
Long-Term Servicesand Supports
Evidence-Based Health Workshops
Medication ManagementCaregiver
Support Services
Stratified Home and Community-Based Services
Increasing Functional or Cognitive Impairment,Decreasing Numbers – Increasing Cost
Evidence Based Health Self-Management
Supported by extensive research
Measurable, proven outcomes to achieve specific goals
Clear, structured, detailed program
Peer-reviewed & endorsed by a federal agency
Peer-led, replicable in many settings
Evidence Based Health Self-Management
• Falls Prevention• Caregiver Support/Early Memory Loss• Chronic Conditions Training
• Chronic pain• Diabetes• Heart disease
• In-Home Medication Management• Home Palliative Care
HomeMedsSM
The Right Meds… The Right Way!HomeMedsSM
The Right Meds… The Right Way!
HomeMedsSM gives you proven solutions in four important problem areas affecting seniors:
1. Unnecessary therapeutic duplication2. Falls and confusion related to possible inappropriate psychoactive medication use3. Cardiovascular problems such as continued high/low blood pressure or low pulse4. Inappropriate use of non-steroidal anti-inflammatory drugs (NSAIDs) in those with high risk of peptic ulcer/gastrointestinal bleeding
www.homemeds.org
The Palliative Care Model
Home Palliative Care
• Care includes MD home visit, 24/7 call (911 replacement), RN, social worker, chaplain, home health aide
• Compared to usual care in Kaiser:Total cost 36% less (p<.001)
Fewer patients use ED (20% vs. 32%) & Hospital (36% vs. 58%) signif @ p<.01
Significantly more likely to die at home (71% vs. 51%: p=.001)
Community Care CoordinationCommunity Care Coordination
In‐Home Assessment& Service Delivery
NurseClient & FamilySocial Worker
Purchased Services (Credentialed Vendors)•Safety devices, e.g., grab bars, w/c ramps, alarms•Home handyman• Emergency response systems•In‐home psychotherapy•Emergency support (housing, meals, care)•Assisted transportation•Home maker (personal care /chore) and respite
services•Replace furniture /appliances for
safety/sanitary reasons•Heavy cleaning•Home‐delivered meals – short term•Medication management (HomeMeds)•Special needs required to maintain independence
Referred Services•AAA •IHSS•Community Based Adult Services
(formerly Adult Day Health Center) •Regional Center•Independent Living Centers•Home Health•In‐Home Palliative Care•Hospice•DME•Families / Caregivers Support Programs•Senior Center Programs•Evidence‐based Health Impacting Self‐
Care programs •Long‐term home‐delivered meals•Housing Options•Communication Services•Legal Services•HICAP•Ombudsman•Benefits Enrollment for services (ie food
stamps) •Money management•Transportation•Utilities•Volunteer services
Integrated Community Care System
One Call Does It All!
CBOCBO CBOCBO
CBOCBOCBOCBO
Network OfficeNetwork Office
For more information
Contact:
June Simmons, CEO
Partners in Care Foundation
818-837-3775
www.picf.org
