Accountability For the Care We Provide

Value and Accountability: Preparing for the Future American College of Healthcare Execu=ves

March 3, 2016

Michael J. Consuelos, MD MBA Senior Vice President, Clinical Integra4on The Hospital & Healthsystem Associa4on of Pennsylvania

• PA trends • How is PA measuring up? • Alterna4ve Payment Models

2

Value and Accountability

Less Need for Inpa8ent Hospital Care

Inpa4ent Admissions per Million

Sources: Pennsylvania Department of Health 3

1.703 1.718

1.685 1.708

1.725

1.686 1.653

1.617

1.578 1.545

1.494

1.350

1.400

1.450

1.500

1.550

1.600

1.650

1.700

1.750

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

4

Freestanding Ambulatory Surgery Centers

Source: HAP analysis of PHC4 data

1,159 1,190 1,144 1,066 1,059 1,043 1,037 1,042 1,055 1,082 1,111

530 620

766 843

895 962 993 986 1,008 1,006 996

0

200

400

600

800

1,000

1,200

1,400

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Hospitals Freestanding ASCs

Outpa4ent Surgeries (000s)

5 5

Hospital Consolida8on in Pennsylvania

68 75

79 77 84 86 83

90 93 99 97

103 110

117 117

122 114

107 104

94 89

85

78 72 64 62

57 48

41 39

-‐

20

40

60

80

100

120

140

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

# Hospitals in Health Systems # Independent Hospitals

1General Acute Care hospitals include community and children’s hospitals. Source: PA Department of Health, data compiled by The Hospital & Healthsystem Associa8on of PA (HAP)

TotalDollarImpact

Total Impact Rank*

TotalDollarImpact

Total Impact Rank*

TotalDollarImpact

Total Impact Rank*

U.S. Impact -‐ -‐ -‐Pennsylvania $2,200,200 4 ($858,700) 39 ($2,070,200) 46

* One is best.

Value Based Purchasing Program

FFY 2014 FFY 2016FFY 2015

The Penalty Box(es)

TotalDollarImpact

Total Impact Rank*

TotalDollarImpact

Total Impact Rank*

TotalDollarImpact

Total Impact Rank*

U.S. Impact ($213,500,200) ($412,132,400) ($419,536,300)Pennsylvania ($8,626,100) 43 ($20,376,100) 45 ($21,572,200) 46

* One is best.

FFY 2016

Readmission Reduction Program

FFY 2014 FFY 2015

TotalImpactedHospitals

TotalDollarImpact

Total Impact Rank*

TotalImpactedHospitals

TotalDollarImpact

Total Impact Rank*

U.S. Impact 720 ($338,343,600) 755 ($336,940,400)Pennsylvania 39 ($19,403,600) 49 39 ($18,088,900) 48

* One is best.

FFY 2016

HAC Reduction Program

FFY 2015

Source: CMS Medicare Quality-‐Based Payment Reform (QBPR) programs for federal fiscal years (FFY) 2014–2016

Exhibit 3. State Scorecard Summary of Health System Performance Across Dimensions

2014 Scorecard Ranking Revised 2009 Scorecard Ranking*Access & Affordabilit

y

Prevention & Treatm

ent

Avoidable Hospital U

se & Cost

Healthy Lives

EquityAccess & Affordabilit

y

Prevention & Treatm

ent

Avoidable Hospital U

se & Cost

Healthy Lives

Equity

1 Minnesota 1 1 1 1 1 Minnesota 1 1 1 1 12 Massachusetts 1 1 3 1 1 2 Hawaii 2 2 1 1 12 New Hampshire 1 1 1 1 1 2 Massachusetts 1 1 3 1 12 Vermont 1 1 1 1 1 2 Vermont 1 1 1 1 15 Hawaii 2 2 1 1 1 5 Connecticut 1 1 2 1 16 Connecticut 1 1 3 1 1 5 New Hampshire 1 1 2 2 17 Maine 1 1 2 2 1 5 Rhode Island 1 1 2 1 17 Wisconsin 1 1 2 2 1 8 Iowa 1 1 2 1 19 Rhode Island 1 1 2 1 1 9 Maine 1 1 2 2 1

10 Delaware 1 1 2 3 1 9 North Dakota 1 2 1 2 110 Iowa 1 1 2 2 2 9 Wisconsin 1 1 2 1 112 Colorado 3 1 1 1 2 12 South Dakota 2 2 1 3 212 South Dakota 2 2 1 2 2 13 Delaware 1 1 2 3 214 North Dakota 1 2 2 3 2 14 Pennsylvania 1 1 3 3 115 New Jersey 2 2 3 1 2 15 Colorado 3 1 1 1 415 Washington 2 3 1 1 2 15 Michigan 2 1 4 3 117 Maryland 2 2 3 2 1 17 Nebraska 2 3 2 2 317 Nebraska 2 1 2 1 3 18 New York 2 2 3 2 119 New York 2 3 3 1 1 18 Washington 2 3 1 1 319 Utah 4 3 1 1 2 20 Kansas 2 2 3 2 221 District of Columbia 1 2 4 3 1 20 Montana 4 3 1 2 222 Pennsylvania 2 1 3 3 1 20 Utah 3 3 1 1 423 Kansas 2 2 3 2 3 23 New Jersey 2 2 3 2 224 Oregon 3 3 1 2 3 24 District of Columbia 1 2 4 3 224 Virginia 2 3 3 2 3 24 Maryland 2 2 4 3 326 California 3 4 2 1 3 24 Oregon 3 3 1 2 326 Illinois 2 2 4 3 2 27 Alaska 4 2 1 3 326 Michigan 2 1 4 3 2 27 Virginia 2 3 2 2 429 Montana 4 3 1 2 4 29 California 3 4 1 1 329 Wyoming 3 2 2 3 3 30 Wyoming 3 3 2 2 331 Alaska 3 4 1 3 3 31 Indiana 2 3 3 3 231 Idaho 4 3 1 2 4 31 Ohio 2 2 4 4 331 Ohio 2 2 4 4 2 33 Idaho 4 4 1 2 434 Missouri 3 3 4 4 3 34 West Virginia 3 2 4 4 234 West Virginia 3 2 4 4 2 35 Georgia 3 4 3 3 336 Arizona 4 4 2 2 4 35 Illinois 3 3 4 3 336 New Mexico 4 4 1 3 3 35 Missouri 3 3 3 4 236 North Carolina 3 3 3 3 4 35 New Mexico 4 4 1 3 336 South Carolina 4 2 2 4 3 39 South Carolina 4 3 2 4 340 Tennessee 3 3 4 4 3 40 Arizona 4 4 2 3 441 Florida 4 3 3 2 4 40 Florida 3 3 3 3 342 Kentucky 3 2 4 4 3 40 Kentucky 3 3 4 4 243 Indiana 3 3 4 4 4 43 Tennessee 3 3 4 4 244 Texas 4 4 3 3 4 44 Alabama 3 2 4 4 445 Georgia 4 4 3 3 4 44 North Carolina 4 3 3 4 446 Alabama 3 3 4 4 3 46 Nevada 4 4 2 4 446 Nevada 4 4 2 3 4 47 Texas 4 4 3 2 448 Louisiana 4 4 4 4 3 48 Louisiana 4 4 4 4 449 Oklahoma 3 4 4 4 4 49 Arkansas 4 4 4 4 450 Arkansas 4 4 3 4 4 50 Oklahoma 4 4 4 4 451 Mississippi 4 4 4 4 4 51 Mississippi 4 4 4 4 4

Note: Several indicators have changed since the 2009 State Scorecard. Therefore, the 2009 Scorecard ranking has been revised to reflect the addition of several new indicators and updated definitions for others. The revised 2009 Scorecard ranking generally reflects the period five years prior to the time of observation for the latest year of data available, though this varies by indicator. If historical data were not available for a particular indicator, the most current year of data available were used as a substitute in the revised 2009 Scorecard ranking.Source: Commonwealth Fund Scorecard on State Health System Performance, 2014.

Performance QuartileTop QuartileSecond QuartileThird QuartileBottom Quartile

Source: Commonwealth Fund May 2014

HHS Makes Historic Announcement January 26, 2015

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Category 1: Fee for Service – No Link to Quality Category 2: Fee for Service – Link to Quality Category 3: Alternative Payment Models with FFS Infrastructure Category 4: Population Based Payment

HHS sets clear goals and 4meline for shi[ing Medicare reimbursements from volume to value

Source: HCPLAN 1/12/2016 h`ps://hcp-‐lan.org/workproducts/apm-‐whitepaper.pdf

2015 HAP Payment Reform Summit “Forging our Path from Volume to Value”

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6%

50% 44%

0% 0%

25%

56%

19%

Fee-‐for-‐service with no link of payment to quality

Fee-‐for-‐service with a link of payment to quality

Alterna=ve payment models built on fee-‐for-‐service architecture

Popula=on-‐based payment

HHS payment framework: Where are HAP members?

Today 2018

50%

31%

6%

13%

How will a shiZ to value-‐based reimbursement affect your organiza=on?

Benefit somewhat

Benefit substan=ally

Lose a li_le

Lose a lot

Not be affected one…

None

Survey:70 clinical, administrative, and financial leaders from hospitals and health systems

Top 3 challenges in preparing for value-based payment:

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0% 10% 20% 30% 40% 50% 60% 70% 80%

Nurse engagement

Administrator engagement

Lack of capital

Other (please specify)

IT infrastructure

Health policy uncertainty

Physician engagement

63%

63%

50%

38%

13%

6%

69%

The Other Challenges

13

•  Lack of reimbursement to support required pa4ent care

•  Pa4ent engagement

•  Movement to value before payment mechanisms catch up and adap4ng to a risk model

•  Lack of control of the full con4nuum of care necessary to make value-‐based reimbursement work appropriately

•  Lack of ac4onable data from payers; living in both FFS and value worlds simultaneously

•  Some4mes the quality measures do not really add value or pa4ent quality

•  Redesign of the health system for popula4on health

•  Have all the providers working in synch

•  Ongoing modifica4on of core measures

Michael J. Consuelos, MD MBA Senior Vice President, Clinical Integration The Hospital & Healthsystem Association of Pennsylvania [email protected]

FROM ANALYTICS TO ACTION –

SPEED, COST & RATIONAL BEHAVIOR REALLY MATTERS NOW

HEALTHCARE EXECUTIVE FORUM - CENTRAL PA

Listening to Employers: How Health Systems Can Support Population Health Management and Accountability for Care We Provide

Thomas Northrop, FACHE - CEO NorHealth Management Group, LLC March 3, 2016

ANALYTICS TO ACTION – Speed, Cost & Rational Behavior

The Landscape �  US Healthcare falls significantly short of potential for: Quality, Consistency, Cost and Access.

�  Determinants of how ‘well’ we live: 40% lifestyle; 30% genetics; 20% - public health & environment; 10% - health delivery.

�  High medical costs, yet Providers have little impact on 90% of life factors. �  ‘More of the same’ behavior in Health sector increases costs, not our results.

�  95% of dollars spent go to medical care, only 5% to population-wide health improvement efforts.

�  Healthcare cost growth far outstrips growth in US disposable income. �  More health spending reduces money available for rest of Economy (education, defense, infrastructure,

social security, etc.)

�  Rate of ‘waste’ in current health spending – 30-50% of dollars spent.


The Landscape (cont.) �  Integrated delivery Systems (Intermountain, Kaiser) have addressed Quality of care and Cost of

care for decades: Not called ‘PHM’ then, simply trying to deliver care/cost balance for patients and community.

�  ‘Accountable Care’ boils down to: (1) Manage fixed-price contracts for the treatment/

management of individual patient health; (2) Apply patient-specific concepts of balancing cost-of-care with quality-of-care to large populations of patients.

�  Data-driven, clinician-led performance improvement combined with market pressures will

produce change. How Long Will It Take? �  For the rest of us, PHM is in Early Development: inconsistent definitions; limited operational

understanding; and hype from vendors combine with misaligned incentives in provider space, payment space and employer space. Result is a far too slow-moving, costly mess. We can do better.


The Landscape (and how to move beyond it)

�  Just 18.2 million U.S. lives now managed under an ACO – very small sample.

�  Current economic models insufficient to drive change. Example from PA data: 6% FFS w/ no link of payment to quality; 50% FFS w/ some link between payment and quality; 44% with alternative payment models based on FFS architecture; 0% with population-based payments in place.

�  New attempts: a) HTA Alliance b) Bree Initiative- Wash State; c) Intel-Portland Collaborative. Good attempts to redefine the game. Basic measures used: 1) Evidence-based care? 2) Patients satisfied? 3) Same-day access? 4) Rapid return to function? 5) Care affordable & savings produced?

�  Value-based payment push will accelerate Winners & Losers – Which will your organization be?

�  Speed, Cost effectiveness, Rational behavior essential.


My View �  Living thru FFS while straddling toward Value-based Pay – Very challenging.

�  Speed of change, Cost effectiveness, Rational behavior are essential.

�  Identify your Biggest Problem Areas (‘vital few’)- Readmits? HAIs? Others?

�  Go after problems NOW - generate Financial Savings & Quality Gains NOW.

�  Use national analytics - Don’t lose time building internal data warehouse first.

�  After Analytics - Determine Action/Process changes required then DO THEM!

�  Build real incentives to change for key players/decision-makers.

�  Seek ‘open architecture’ collaborative access learning … Learn, Learn, Learn.

�  Adjust as needed based on results.

�  Use achieved savings to build internal data warehouse for future gains.


Cost-effective Innovation –

�  Healthy Partners - 400+ San Diego physician group (Key Benefits Group). Direct Employer contracting thru self-funded Ins. Establish proven Care Regimens based on evidence-based medicine – Operates on gain-sharing that rewards Providers for reducing each Employer’s net health spend.

�  MDwise, Inc - 330,000 Pt Indiana-based Medicaid/vulnerable patient group. (ZeOmega’s Jiva

pop hlth mgmt app). Disease/case mgmt reduces SNF Readmits & ER visits: 66% less readmits, 61% drop in Pt LOS.

�  U Miss Med Ctr - “Analysis of initial Pt group with (Jvion RevEgis app). Acute Myocardial

Infarction case prediction nearly two times better than with Stress tests, 20% better than CT coronary angiograms in predicting AMI events in low risk pop. w/in 12 months of discharge.” Dr. John Showalter, UMMC Chief Hlth Information Officer. Video: www.jvion.com/client.html


Sequential PHM Criteria (Typical) Use criteria to build roadmap & evaluate progress. Get started NOW. Reasonable yet aggressive typical

roadmaps & timeline include:

Year 1 - Pt Registries, Patient Attribution.

Year 2 - Precise Numerators, Clinical & Cost Metrics.

Year 3 - Clinical Practice Guidelines, Risk Management Outreach. Year 4 - Acquiring External Data, Patient Communication System, Patient Education/Engagement System.

Year 5 - Complex Clinical Production Guidelines, Care Team Coordination System, Pt Specific Clinical Outcomes System.

[*PHM ‘Criteria’ used with permission approval of Health Catalyst, Inc.]


Recommended Time/Cost Sequence

�  Five years is far too slow to generate savings and results.

�  Identify your biggest presumed problems impacting Revenue/Quality.

�  Access ‘external national data’ now as temporary ‘data warehouse surrogate’.

�  Evaluate external data against your ‘vital few’ clinical/financial indicators.

�  Confirm accuracy of ‘vital few’ indicators in your organization then act on them.

�  Build multiple ‘Change Teams’ to address process changes needed.

�  Develop/implement/assess Incentives needed to support changed behaviors.

�  Monitor, Adjust, Improve further … based on results achieved thus far.

�  Pursue addtl key clinical/financial challenges from your organization.

�  Use achieved savings to invest in future internal Data Warehouse.


�  Questions & Discussion


�  Thank You!

Thomas Northrop, FACHE – CEO NorHealth Management Group, LLC [email protected] 804-405-4983 March 3, 2016

Accountability for the Care We Provide

Health Care Executive Forum of Central PA March 3, 2016

Gerald Walsh Vice President, Provider Contracting & Relations Highmark Inc.

HIGHMARK.COM

“Accountable Care”

Beyond CMS’ Rules and Regulations

An Insurers Perspective

ACO Defined The ACO concept is one that is s4ll evolving,… a group of health care providers...who voluntarily come together to provide coordinated high-‐quality care to popula4ons of pa4ents. The goal of coordinated care provided by an ACO is to ensure that pa4ents and popula4ons — especially the chronically ill — get the right care, at the right 4me and without harm, while avoiding care that has no proven benefit or represents an unnecessary duplica4on of services.

27

Source: Health Catalyst (What is an accountable care organiza4on), Dr. John Haugom and Dr. David Burton

The Institute for Healthcare Improvement

28

My Point of View

• Clinical/Care Management of a Population

• Total Cost of Care - Measured

• Quality – Measured

• Patient Satisfaction

• Shared and Aligned Reward

29

Change the Conversation

Why spend your valuable and limited time on developing a provider – payer relationship around an accountable care model?

The 10 Things CEOs Need to Know in 2015 (The Advisory Board Company, Research Briefing, 2015)

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32

The 10 Things CEOs Need to Know in 2015 (The Advisory Board Company, Research Briefing)

Payment Continuum

33

Fee for Service

P4V Incentives

Bundles Gain Share Risk Share % of Premium

34

The Advisory Board Company, Care Transformation Center Population Health Survey Results, 2014

Medicare is pushing you in this direction Your making investments in people and tools Maximize your investments and create efficiencies

Consumerism (B2C)

35

Price

Network

Key Components and Key Challenges of a

Payer – Provider Accountable Care Relationship

37

Key Components of a Commercial Payer ~ Provider Accountable Care Relationship Attributed Population Physician Leadership – Champions Clinically Integrated Network Primary Care Driven Care Coordinators Post Acute Care Collaboration Information Sharing – Bi-directional Quality Metrics Financial Alignment Governance Committee Measureable Goals

Key Challenges

38

Population Health

Management

Trust

Data Share

and Use

Key Challenges: Data Share and Use (beyond reports from health plans)

•  Will/Can the health plan share claims data : raw or filtered? •  Will/Can the provider share clinical data? •  Who houses the data (health plan, provider, third party)? •  What tools and technology will be used and who pays for it?

•  Can the tool match clinical and claims data?

•  Is the reporting real time and robust enough? •  How do you make it actionable?

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“Almost 12% of providers who responded to our survey even said that there would be a positive impact on their organizations if their health plans stopped sending data.”

The Advisory Board Company, 2015 HIPAC Data-Sharing Survey

Data Use Agreement

Key Challenges: Population Health Management

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www.urgentcareadvisors.com

Define It ID a population

Who will do what?

How will it be

funded?

Key Challenges: Trust

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