Sustaining Population Health Outcomes

William J. Kassler, MD, MPH

Practical Playbook MeetingMay 2016

U.S Health in International Perspective

• US spends far more per person on health care

• Shorter life span, Poorer health

• Consistent and pervasive over entire life:

Infant mortality & low birth weight

Injuries & homicides

HIV/AIDS

Drug-related deaths

Obesity & diabetes

Heart disease

Chronic lung disease

Disability

Factors that Determine Health

Adapted from Kindig JAMA 2008; 299(17): 2081-2083.

Number of Deaths from Behavioral Causes

Source: Mokdad et al JAMA 2004

Impact Of Obesity On Medical Spending: 1987 – 2001

• Obesity increased by 10% in population

• Spending for obese was 37% higher

than for non-obese

• Rate of growth in spending higher for

obese:

63% ↑ obese vs. 37% ↑ non-obese

• Obesity accounted for 27% of growth in

spending

Thorpe et al Health Affairs, no. (2004):10.1377

Socio-economics factors linked to poor health outcomes

• Area Deprivation Index (ADI)– Neighborhood-based composite measure

consisting of 17 markers of socioeconomic status

• ADI correlated with:– Mortality rates (age and race adjusted) for men

and women

– 30 day readmission rates • increase with worsening ADI

• Magnitude equal to COPD and > diabetes

Sources:Singh, GK Area deprivation and widening inequalities in US mortality, 1969-1998. Am J Public Health July 2003Kind, AJ et al Neighborhood socioeconomic disadvantage and 30-day rehospitalization: a retrospective cohort study Ann Intern Med Dec 2014

Health vs Social Services Expenditures

Determinants

SOCIAL, ENVIRONMENTAL, and BEHAVIORAL

FACTORS(60%)

GENETICS(20%)

HEALTH CARE(20%)

8

HEALTH CARE SPENDING

(65%)

SOCIAL SERVICE SPENDING

(35%)

InvestmentMismatch

Courtesy of Elizabeth Bradley

Investing in Social Services

How?

Population Management

vs

Total Population Health

Reconciling the clinical perspective with a broader community perspective

Community:

Public Health, Social Services

sectors

Health Systems: Hospitals, ACOs,

Health Plans

Clinical Practices: Primary Care

Medical Homes, Specialty Care

Subgroups of Patients:

Panels, Racial/Ethnic

groups, patients with specific

chronic diseases

Based on Kassler et al. N Engl J Med 372; 2015

Clinical Practices

• Population-based approaches:– considering what happens between visits– using registries and tools to improve preventive care– addressing health disparities by including social, economic,

and cultural factors– referring patients to a wider range of community services

• Supportive strategies:– Medical homes and care management payments– Linking practices and patients to community supports– Practice support (Transforming Clinical Practice Initiative)– Community Health Workers - translation, appointment

scheduling, referrals, and transportation

Delivery Systems

• Population-based approaches:– Assessing community health needs

– Investing community benefit dollars

– Collaborating with other organizations to support nonmedical services delivered in community settings

• Supportive Strategies:– Performance based alternative payment models

(e.g. ACOs) incentivize investments

Health Plans

• Medicaid and Medicare contracts afford greater flexibility than FFS to pay for population services

• Some MCOs cover bicycle helmets, car seats, participation in the YMCA’s Diabetes Prevention Program or March of Dimes Baby and Me Tobacco Free program

Medicaid Managed Care

Positively Impacting Social Determinants of Health: How Safety Net Health Plans Lead the Way June 2014

Leveraging Medicaid contracts through sponsorships,

grants, and partnerships to invest in:

• Housing support,

• Employment initiatives,

• Literacy programs,

• Services for overcoming food insecurity.

Communities / States

• Medicaid

– Historically covers many non-medical support services

– Waivers & Demos provide additional opportunities to invest in upstream strategies (Vermont waiver)

• State Innovation Models

– Use multiple levers for health systems transformation

– Population health plans

• Accountable Health Communities

Accountable Health Communities Model Intervention Approaches

• Track 1: Awareness – Increase beneficiary awareness of available community services through information dissemination and referral

• Track 2: Assistance – Provide community service navigation services to assist high-risk beneficiaries with accessing services

• Track 3: Alignment – Encourage partner alignment to ensure that community services are available and responsive to the needs of beneficiaries

Looking ahead: MACRA

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

is a bipartisan legislation signed into law on April 16, 2015.

• Repeals the Sustainable Growth Rate (SGR) Formula

• Changes the way that Medicare rewards clinicians for value

over volume

• Streamlines multiple quality programs under the new Merit-

Based Incentive Payments System (MIPS)

• Provides bonus payments for participation in eligible

alternative payment models (APMs)

CMS has adopted a framework that categorizes payments to providers

Payments are based on volume of services and not linked to quality or efficiency

Category 1:

Fee for Service – No Link to Value

Category 2:

Fee for Service – Link to Quality

Category 3:

Alternative Payment Models -- Built on Fee-for-Service Architecture

Category 4:

Population-Based Payment

At least a portion of payments vary based on the quality or efficiency of health care delivery

Some payment is linked to the effective management of a population or an episode of care

Payments still triggered by delivery of services, but opportunities for shared savings or 2-sided risk

Payment is not directly triggered by service delivery so volume is not linked to payment

Clinicians and organizations are paid and responsible for the care of a beneficiary for a long period (e.g., ≥1 year)

Source: Rajkumar R, Conway PH, Tavenner M. CMS ─ engaging multiple payers in payment reform. JAMA 2014; 311: 1967-8.

Lessons Learned: ACOs

• Demographics vary …– Urban/rural, large/small, HIT, populations served

• ... But culture similar– Focus on value & population perspective before

started ACO

– Emphasis on strengthening primary care(e.g. built on integrated medical home)

– History of coordination across sites of care(e.g. leveraged pre-existing relationships/focus on transitions)

– Strong clinician leadership / engagement

– Familiarity with data

Strategies for Sustainability

• Embed population health

– Value-based payments (MIPS metrics and incentives)

– Advanced APMs

• Support infrastructure development

• Partnership, collaboration and alignment across sectors

• Lessons learned from model testing

Hospitals’ Role in Population Health:

• To retain tax exempt status, non-profit hospitals must:– Conduct “community health needs assessment” every 3 yrs

– Adopt implementation strategy to meet the community health needs identified through the assessment

• Community Building. IRS-approved activities:– Leadership development / training for community

– Community health improvement advocacy

– Physical improvements and housing

– Coalition building

– Economic development

– Community support

– Environmental improvement

– Workforce development

Next generation models?

• Incentives for cross-sector collaboration

– CHNA, Community Building

• Risk adjusted payments for poverty

• Community incentive payments (e.g. tobacco)

• Social Impact Bonds

Challenges

• Fiduciary constraints on payers

– Funding non-medical services & upstream approaches

– Funding services for non-beneficiaries

• Scale-up from testing to implementation

– Time horizon and actuarial standards

• Provider scope of practice and accountability

• Measurement and data infrastrucure

Policy – Related Research Priorities

• Paucity of effectiveness data on psychosocial interventions – associated culture of resistance to evaluation

• Behavioral economics

• Emerging role for local public health agencies

• Practice infrastructure to manage populations

• Measurement

• Health disparities

• Collaboration and consolidation

Thank you