140306 dr tim ferris healthcare cost challenge

Division of Population Health Management

Partners Approach to Meeting the

Healthcare Cost Challenge

Timothy Ferris, MD, MPH SVP, Population Health Management, MGH, MGPO and Partners

HealthCare

Nuffield Trust Health Policy Summit 2014 March 6, 2014


What we’re facing…

Constraining the growth of healthcare costs is a national priority

Involvement of physicians through changed incentives is unavoidable

PPACA - the imperative will persist even if the specifics change

The market is using a similar play book – closed networks,

budget-based risk, cost sharing, restriction of choice – and this

may generate the same backlash as 1990s managed care era

But...

The economy is much worse

Government is proactive (3.6%)

Rate of change is slower (caps on increases, not cuts)

And we have…

Better health IT and data for population management

Strategies and tactics that we know will improve care and reduce costs

2


Implications for providers

Our focus should be on reducing medical expense trend to as

close to the rate of general inflation as we can

We want to be part of the solution

This means taking financial risk for costs of care

Shared savings (Pioneer ACO), bundled payments, global payments

Partners increased ability to care for populations of patients

Successful CMS Demo, increasing evidence for other tactics

Universally adopted EHR

Challenges

1. We need tactics that will be successful under any new payment model

2. How to make external incentives meaningful to our physicians

3. Moving at the right pace

Too fast: we will lose the docs in the rush to implement – MDs attitude

often creates the patient's attitude (managed care backlash)

Too slow: will mean not succeeding under the contracts and worsening

the regulatory environment

3


What is an ACO?

An organization that agrees to share the financial risk for the care of a

defined population

Shared financial risk =

rewarding providers for

reducing medical spending

by giving them a share of the

net cost savings; may also

include financial penalties for

cost increasing above

benchmark

Defined population = every

primary care patient whose

insurer has signed a risk

contract with that provider,

regardless of where they

receive care Source: Leavitt Partners Center for Accountable Care Intelligence at

http://healthaffairs.org/blog/2014/01/29/accountable-care-growth-in-2014-a-look-ahead/

Total Accountable Care Organizations by

Sponsoring Entity

Total = 606

4

http://healthaffairs.org/blog/wp-content/uploads/Muhlestein-Chart-2.gif


Evolution of ACOs

Estimated Accountable Care Lives in Public

and Private ACOs*

Accountable Care Organizations by State*

18.2m covered lives compared

to 13.6m at end of 2012

•More than half of the US population (52%)

live in primary care service areas served

by ACOs, approximately 28% live in areas

served by 2 or more ACOs.**

•Los Angeles, Boston, and Orlando, have

the most ACOs in the nation.* In Boston,

ACOs care for more than 60% of

patients.***

*Leavitt Partners Center for Accountable Care Intelligence at


**http://www.oliverwyman.com/media/ACO_press_release(2).pdf

***http://www.acpinternist.org/archives/2013/07/acos.htm

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Background on Partners HealthCare

Partners HealthCare (Partners)

Integrated delivery system in Boston MA, includes two

AMCs

Massachusetts Hospital (MGH)

Brigham Women’s Hospital (BWH)

Partners became a Pioneer ACO, January 2012

Includes community and specialty hospitals, a physician

network, home health and long-term care services, and

other health-related entities

615 PCPs

76,000 patients

6


Enhanced access to specialty

services

The path we’re traveling at Partners

7

Pressure to reduce

cost trend

New contracts with

risk for trend

Internal Performance

Framework

Investment in Population

Management Infrastructure

Changes to Partners

org structure

Partners in Care (PCMH & care

coordination for high risk patients)

Sustained cost trends near GDP

Implement new local

incentives/compensation

Network Affiliations

1

2

3 New relationships with

community hospitals and

doctors

4


Our new contracts…almost 2 years in Lives under the Accountable Care Model

Medicare Commercial

Pioneer Accountable

Care Organization

Elderly population,

care management

central to trend

management

Alternative Quality

Contract (AQC)

Younger population,

specialists critical to

management

2 1

Medicaid

NHP

Population with

significant disability,

mental health, and

substance abuse

challenges

3

Self Insured

Partners Plus

Commercial

population, but

savings accrue

directly to Partners,

and improves our

own lives

4

Covered lives: ~80k Covered lives: ~25K Covered lives: ~350K Covered lives: ~75k

Partners currently manages roughly 500,000 lives in various accountable care relationships

8


Priority programs

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Priority Population Health Management Programs Primary Care •Patient Centered Medical Home (PCMH), including especially

access •High risk care management •Mental health

Specialty Care •Referral management •Virtual visits •PrOE/PROMs •Bundles

Care Continuum •SNF networks •Mobile observation units •Urgent care

Patient Engagement •Shared decision making •Virtual patient communities •Customized risk and educational materials

Infrastructure •IS, analytics •Program management


Virtual visits and technology tools

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Email

Video

Conferencing

Telephone

Text

Messaging

Electronic

Curbside

Technology Pediatric Virtual Video Pilots •Follow up visits in the home for children and adolescents with Autism, ADHD, Substance Abuse, etc,

•Post-acute burn consults for patients at Boston-Spaulding Rehabilitation Hospital

•Parents of patients in the PICU virtually attend rounds with care team and their child

35 48

313

Pediatrics Burns Center Child and AdolescentPsychiatry

17

2

0%

20%

40%

60%

80%

100%

Cardiology

Resulted in Visit

Curbside ConsultPerformed

Cardiology Curbside Consults*

*Start of pilot Jan 2014

•Referring physicians can quickly contact a cardiologist in the outpatient setting and receive recommendations in the electronic medical record •Offers referring providers and patients an alternative to waiting for in-person cardiology appointments


Chen, A. H., Kushel, M. B., Grumbach, K., & Yee, H.F. (2010). Practice profile:.A safety-net

system gains efficiencies through ‘eReferrals’ to specialists. Health Affairs (Millwood), 29(5),

969-71.

Why is this important?

Assessing the appropriateness of referrals prior to scheduling may have

a positive impact on our efforts to

Reduce avoidable office visits

Increase access for our sickest patients

Increase experience coordination and efficiency of specialist visits

through pre-visit planning

Approaches for managing referrals

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Idealized patient journey through an episode of

care that includes a procedure

Patient

Problem

Assess

Appropriateness

Criteria Assess

Risk

Schedule

OR Procedure Recovery

Physician

encounter

Possible

Need for

Procedure

Shared

Decision

Making

Pre-

Procedure

Testing

Tier 1, 2

Outcome

Measures

Tier 3

Outcome

Measures

Personalized

Consent

Form

Informed

Consent

Tier Category Examples

1 Health status achieved Survival and degree of health recovery

2 Process of recovery Time to recovery and return to normal

activities

3 Sustainability of health Sustained recovery and recurrences,

including long term consequences of

therapy

Outcome measures hierarchy:

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Appropriateness

Data Repository

Procedure

Scheduling

PrOE Appropriateness tool

Public

Reporting

PCI, CABG,

Vascular,

Harris Joint

Internal

Performance

Dashboards

Billing and

Prior

Authorization

RPM,

RPDR,

CDR,

EMPI

Pre-

populated

data fields

(NLP

search)

INPUTS OUTPUTS

Personalized

consent

form Existing

registries

LMR, OnCall

Data

storage

EMR

Appropriateness

Indications & Decision

support

Measurement & analysis of

appropriateness and

outcomes inform guidelines

and indications in real-time

Data passback to

registries (Web

service)

Copy of

appropriateness

results placed in

LMR and CDR

EHR note

created

PrOE: Inputs and outputs

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CAS CEA CABG DiagnosticCatheterization

Not in PrOE

In PrOE

Percent of Procedures with a PrOE Assessment

Appropriateness Scores for Diagnostic

Catheterization by Month

2014 Procedures •Incisional Hernia •Prostate Biopsy •Gastric Bypass •Valve Repair •Lumbar Fusion •Peripheral Vascular Disease Therapies

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Aug Sept Oct Nov Dec

Rarely Appropriate

Maybe Appropriate

Appropriate

Median hospital-level inappropriateness rate is 28.5%**

**Hannan, EL, et al. Appropriateness of Diagnostic Catheterization for Suspected Coronary Artery Disease in

New York State. CIRC INTERVENTIONS. January 28, 2014. 113.000741 n=745

n=8986

Median hospital-level inappropriateness rate is 28.5%**

Appropriateness Scores for Diagnostic

Catheterization at MGH vs. NY Cardiac Database **

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

MGH NY CardiacDatabase

RarelyAppropriate

MaybeAppropriate

Appropriate

Results to date

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Patient Reported Outcome Measures (PROMs)

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Outcomes that matter to patients: direct collection of information from

patients regarding symptoms, functional status, and mental health.

Why PROMs?

Improves care of individual patients through better

monitoring and improved responsiveness

Improves system-wide care by measuring/improving the right

outcomes – those that matter most to patients

How are PROMs collected? Patients enter information into an electronic platform using

iPads, patient portal, or the web

PROMs will be implemented for all sites and

diagnoses

Current Conditions include: Coronary Artery Disease: CABG, Cardiac Catheterization

Osteoarthritis

Valvular Disease

Diabetes

Depression

Additional conditions planned for 2014


What does PHM cost?

Total Cost PHM Programs

(Annual Operating & 1x

expense)

PHM Cost as a Percentage of External Risk TME (At 2017 Steady State Run Rate)

PHM Program Costs as a Percentage of External Risk TME only

Total Costs as Percentage of External Risk TME only

4.96%

4.96%

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What is the ROI?

$0

$50

$100

$150

$200

$250

2015 2016 2017

Total PHM Acceleration Cost

Savings from External Risk

Savings from full IPF

Savings from full panel (Loyalty Cohort)

PHM Program Savings Relative to Total Operating Program Costs (Assumes Steady State in 2017)

•Two-thirds of PHM acceleration costs fund programs that generate TME savings

•Remaining funds support infrastructure, innovative pilots (i.e. SNFist), community specialist engagement that accrue minimal or difficult-to-measure savings

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Key Challenges

Overlapping programs and contracts (e.g. Chronic Disease Demo)

Timely data and useful performance measures (CMS delays with delivery of prospective patient information)

Transition costs—establishing the EHR infrastructure Funding the infrastructure (no grant funds)

Intersection between the multiple Boston area ACOs

Notification management

ED notification

Discharge notification

Sharing of best practices between colleagues

Learning what works and providing timely feedback for policy changes/enforcements to CMS

Limited leverage when patients seek covered services that provide little or no benefit

Time to ROI not consistent with duration of contracts

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Health & Medicine

140306 dr tim ferris healthcare cost challenge