Putting Patient First Cynthia Kilroy PH Alliance Dec 11 2014

Putting Patients First Cynthia Kilroy, SVP Consumer Strategic Solutions

PH Alliance, December 11, 2014 1

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Learning objectives

Identify the fundamentals to manage a population 1

Identify population risk stratification models to determine appropriate care models

2

Ensure the allocation of resources to deliver optimal outcomes and effective risk management 4

Define a consumer-centric approach grounded in an individuals attitude and behavior to health 3


WHERE DO WE BEGIN?

Improving health care quality, lowering costs, and improving health status for consumers, employers, payers, government and care providers is the ultimate objective …


What does it take to manage a total population?

4

Clinical Transformation 1

Population Health Focus 2

• Evidenced-based medicine • Integration across the continuum • Physician participation in governance

Service Distribution Effectiveness 3

• Innovative care delivery models • Personalized patient engagement • Manage health longitudinally

Financial Stability 5 • Financial and clinical risk management • Investment/Appropriate use of resources • Aligned payer contracts

• Board primary care base • Seamless referrals • Care at lowest cost setting

IT Sophistication 4 • Clinical and behavioral analytics • Digital Health/TeleHealth • Integration of information


of providers and healthplans involved in accountable care consider analytics their top investment priority

Source: 2014 Health Catalyst: Analytics Outweighs Accountable Care, Population Health, ICD-10 as an IT Priority


Actionable knowledge begins with the right data

• Analytics to predict future medical costs of individuals and populations are limited by the characteristics of the types of available data:

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Claims Data Clinical Data

Socio-Demographic

and Care Management Data

– insensitive

– non-specific

– untimely

+ always available

+ sensitive

+ specific

+ timely

– variably available (may be incomplete or

unstructured in EMR, or unavailable from

non-EMR users)

+ sensitive

– non-specific

+ timely

+ generally available

Presenter

Presentation Notes

LESLIE: Karen did an awesome job slide. She communicated why we need all these types of data to get a 360 view to be considered ‘good’ data. Claims Data: Most often obtained from payers or medical or pharmacy benefit managers Clinical Data: Found within electronic medical record (EMR), biometric feeds, lab feeds, pharmacy feeds or health assessments (by either the patient or care manager) Socio-demographics and Care Mgmt. Data: May come from hospital �notice of discharge, admission, ED visit or skilled nursing facility transfer Relative strengths of data used in health care analytics vary by source, and can be categorized by sensitivity (ability to detect all conditions), specificity (ability to identify conditions accurately), timeliness and availability. Variations in strengths and weaknesses between these three data sources suggests aggregation will provide a more effective basis for prediction of future medical outcomes and costs.


Understanding the population risk segments identifies value opportunities

Population Segmentation with Illustrative Population and Spend

*Modifiable Risk Factors: Smoking, Obesity, High Blood Pressure, Occupation, High Cholesterol, Stress, Drug or Alcohol Abuse **Conditions: Cancer, COPD, CHF, Asthma, Diabetes, Depression, CAD, Cirrhosis ***Rare Conditions: CF, AIDS/HIV, MS, ALS, Gaucher’s, Parkinson’s, RA, Lupus, Sickle Cell, Hematologic Disorders, Hemophilia, Dermatomyositis, Polymyositis, Scleroderma

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Health Advocates Primary Care (PCMH)

Chronic Care Management Specialty Clinics

Comprehensive Care Clinics

Extensivist AICU

Segment Healthy

and Early Stage at

Risk

Early Stage Chronic

Complex Acute

Severe Behavioral

Chronic High

(Interventional)

Rare High Cost

Condition

Poly chronic Catastrophic

Definition

No current diagnosed conditions

and low risk factors

Lowest 75% of medical spend with

one condition

Top 5% of medical spend without defined

disease or condition

Patients with severe

behavioral disorder with

no other condition

Top 10-25% of medical spend with

one or more condition

Patients with complex/ specialty

conditions requiring

specialized care

Top 10% of medical

spend with 2 or more conditions

Top 2% of medical spend

with define disease and

condition

Avg. Cost Per Member $232 $164 $2,354 $555 $592 $825 $1,817 $7,347

Approx. % of Population 56.6% 11.6% 0.7% 14.4% 7.7% 1.5% 2.4% 2.3%

Avg. Risk Score 0.62 1.12 1.82 1.47 2.02 2.93 3.74 6.26

Approx. % of Spend 20.4% 3.4% 2.9% 14.2% 9.1% 2.9% 8.6% 33.6%


Population Health Care

Delivery Models • Hospitalists • Centers of Excellence • Inpatient Care Management • Surgical Focus Factory

• Health Coaches • Specialty Clinics (i.e. Heart Failure) • Chronic Care Management • Specialty PCMH (i.e. ESRD,

Diabetes) • Comprehensive Care Clinics

• PCMH • Extensivists (by segment) • Ambulatory ICU • Complex Pediatrics • Integrated Behavioral/Medical • Palliative Care

• Integrate Home Health • SNFist • Hospital at Home • Hospice Care

• Urgent Care • Convenient Care • Wellness Clinics • Health Advocates

Different population health care delivery models ensures a holistic approach

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Individual behavior accounts for

of health status 80% the #1 determinant, ahead of environment, genetics and access.


Personalized health care evaluates an individuals motivations and behaviors

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What consumers say they do and want (Attitudes)

What consumers actually do

(Behaviors)

Who consumers are ((Demographic)


Evaluating an individual’s motivation and attitudes

• 3,600 individuals interviewed across multiple and diverse markets

• Questions focused on

– 106 Motivational Statements

– 10 Behavioral Dimensions

• Resulted in 12 Primary Segments

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• Perceived Health Status

• Healthy Lifestyle

• Solution Seeking

• Financial Well Being

• Health System Usage

• Access

• Demand for Innovation

• Need for Guidance Support

• Relationship with Providers

• Insurance / Payer Trust

• Hunger for information


Seven attitudinal segments go beyond demographic and health identifiers

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Assured Actives Trusters Uninvolved Progressive

Preventers Overwhelmed Strivers

More Healthy Less Healthy

Motivated Seekers

Get health care advice at the gym from trainers and

friends

Solution seekers that are open to new ideas and prefer

homeopathic options

Like the health system and trust their

doctor; do what their

doctor recommends

Don’t think about health and aren’t

searching for options or

advice; resist changing lifestyle

Prioritize health last

behind work and family;

need convenience

Motivated to take care of themselves and search for solutions

Knows they should follow

doctor’s advice, but

confused and don’t know

where to begin


Attitudinal segments defines relationship between confidence and awareness

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Low confidence High confidence

in navigating their health, benefits and the system

Low awareness

High awareness of own health needs

Overwhelmed

13%/24% Motivated

14%/25%

Trusters

16%/13%

Assured Actives

15%/9%

Striver

15%/13%

Uninvolved

14%/9%

Progressive Preventor

13%/7%

% of Population/% of Spend

Presenter

Presentation Notes

Health status alone is not indicative of engagement. It’s important to look at the. Upper-left quadrant = Requires low investment to move, greatest opportunity Aware of health needs, tends to be less healthy, but not confident in navigating his health, benefits or system. Needs guidance and support. Lower-left quadrant = Requires significant investment to move Difficult to engage because doesn’t know her health needs and is low utilizer of services.


Next Frontier: Intersection of Information Drives Population Care Models


Intersection of attitudinal and population risk segments results in four key patient profiles

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Attitudes

Clinical Risk

Overwhelmed Striver Progressive Preventer Motivated Seekers Uninvolved Assured Actives Trusters

Healthy Modifiable At Risk Early Stage Onset Complex Acute Complex Chronic Rate High Cost Poly Chronic Catastrophic

Value (Risk) High

Low

Low High Attitude

Uninvolved Chronic

High Value / Low Activation

Engaged Chronic

High Value / High Activation

Healthy/At Risk

Low Value / Low Activation

Proactive Wellness Seekers

Low Value / High Activation

Value: the individual burden (i.e. risk) on the system Activation: Measure of ownership of one’s health by level of interaction with the system

Patient Profiles

Presenter

Presentation Notes

Move around – acute events could move them but you could also move them


Health Coach

Aligning patient profiles with resource allocation to support population health

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Value (Risk) High

Low

Activation Low High

Health Coach Care

Manager Physician

Care Manager

Physician

Health Advocate

Physician

Support healthcare questions and navigate the system on an as needed basis

Health Advocate

Physician

Gain healthcare knowledge, navigate the system and monitor health status to proactively maintain health

Health Coach

Uninvolved Chronic Engaged Chronic

Healthy Proactive Wellness Seekers

Health Coach

Support personalized education and guidance to help gain confidence to become engaged

Proactively engage to support a personalized care management plan

Self-Service Self-Service

Self-Service Self-Service


Population Care Delivery Models

Merging patient profiles with population care delivery models

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Patient Profiles

Episodic Care

Management Models

Chronic Care Management

Models

Post Acute Care Models

Preventive Care Models

Primary Care Models

• Understand the needs by markets: Medicare, MA, Medicaid, Commercial • Determine where populations and individuals fall within patient segments • Evaluate most appropriate delivery model investments based on market

need and spend • Not a one size fits all

Thank you.

For more information, contact:

www.optum.com/aco

[email protected]

800.765.6619

Healthcare

Putting Patient First Cynthia Kilroy PH Alliance Dec 11 2014