Randall D. Cebul, MD
Better Health Partnership: Approach, Accomplishments,
and Investments
Director, Center for Health Care Research & Policy CWRU at MetroHealth Medical Center
President and CEO, Better Health Partnership
betterhealthpartnership.org [email protected]
October 9, 2015
Better Health’s Vision and Mission
To Help Northeast Ohio Become a Healthier Place to Live and a Better Place to do Business
By creating a safe space for health care
competitors to collaborate
Common RHIC Themes • Multi-stakeholder • Improve care, outcomes,
and costs for [adults] with chronic conditions
• Focus on primary care • >50% saturation of “health care market”
• Support Region-wide QI • Publicly report results • TRIPLE AIM
RWJF’s Aligning Forces for Quality Regional Health Improvement Collaboratives (RHICs)
2007–2015
Special Features of Better Health’s Collaborative
• Led by providers • Partnerships with state govt, public health agencies and
academia in addition to employers and health plans • Prominent focus on safety net and reducing disparities • Electronic medical records used for all clinics’ quality
measurement, public reporting and improvement • Identifiable patient-level “social determinants” – race,
insurance status, language preference, income and educational attainment
Berwick’s Triple Aim
Be#er Care Be#er Health
Lower Costs
BETTER CARE and BETTER HEALTH Using Publicly Reported Data and
Shortening the Path to Improvement
6
What We Measure, Report and Work to Improve
Measurement - at the heart of everything we do…
• Care and Control of Diabetes (2007-), Heart Failure (2008-), and Hypertension (2009-)
• Depression Screening (2012-) • Patient Experience (2012-) • Disparities across the region
EMR-based Measures to Reduce Disparities and Improve Population Health
(2014: 170K patients)
• Insurance • Race • Hispanic Ethnicity • Language Preference • Sex • Geographic Location • Household Income* • Education* * from ACS/Census
• Body-Mass Index • Blood Pressure • Smoking Status • Depression Status
Reducing Disparities in northeast Ohio
Better Health’s 10 Safety Net Systems
• Asia Services in Action • Care Alliance Health Center • Free Medical Clinic of Cleveland • Lake County Free Clinic • Louis Stokes VA Medical Center • MetroHealth System • Neighborhood Family Practice • North Coast Health • NEON • St. Vincent Charity Medical Group
Safety Net Orgs (SNOs) vs. Others: Competing in a safe space, level playing field
Patients with Diabetes, 2014
Reducing Racial Disparities in Diabetes Care
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Safety Net
Income Disparities and Pneumovax
Our Secret Sauce for Improvement
“Who are those guys? How did they do that?”
Butch Cassidy (Newman) and the Sundance Kid (Redford)
1969
A Sauce for Improvement, not a Silver Bullet
1. Find the bright spots in our data (“those guys”)
2. Interview key informants - write up what they did
3. Disseminate the process in a safe space (here)
4. Re-measure adopters to see if they improved too 5. If they have improved, we have another
(Evidence-based) Best Practice.
Ingredients and Steps
2011-12: Finding Best Practices for Good Blood Pressure Control
50
69
81 83 83 84 85 86 87 89 89 90
0 20 40 60 80 100
REGION
-‐6
0 0 0 1
6 7
9 11
13 14 14 14 14
16 -‐10 -‐5 0 5 10 15 20
REGION
Bright Spots for Good BP control: The best 10 were from one system
Bright Spots for improvement: The top 6 were from the same system
“What system is this? How did they do that?”
Kaiser Permanente (now HealthSpan)
Improving BP control (2012-14) using HealthSpan’s Best Practice in the safety
net
25% improvement!
Regionwide change
Gold Star PracMces -‐ CongratulaMons !
Improving Care and Health: What about Costs of Care?
Projects that use our community
as a Learning Laboratory
Cost of Care Projects/Analyses 1. The Better Health Experiment (2009-11) – have
the number and costs of “preventable” hospitalizations declined?
2. The Red Carpet Care program (2012-13) – did a health plan-supported “super-utilizer” project reduce pmpm costs?
3. MetroHealth Care Plus (2013) – did a “closed panel” Medicaid waiver program improve quality/save $$s?
4. “Primary Care Push” (2012--)– will an employer-supported PCMH program at Lake Health improve quality and reduce costs?
The “Better Health Experiment”
• Better primary care should reduce the rate of “ambulatory care sensitive hospitalizations”
• Our primary care providers care for ~70% of adults with chronic illnesses in Cuyahoga County.
• Using an all-payer hospitalizations dataset, we asked whether preventable hospitalizations declined more in Cuyahoga County than in 5 other large Ohio counties.
Reducing Preventable Hospitalizations 2009-11: Cuyahoga Co. vs Other Large Counties
Averted Hospitalizations Increased Each Year
AVERTED: 2,200 HOSPITALIZATIONS $15.4 MILLION IN COSTS
532 ($3.5M)
830 ($5.7M)
848 ($6.3M)
2,210 ($15.4M)
0
500
1,000
1,500
2,000
2,500
2009 2010 2011 Total
# of
Hos
pita
lizat
ions
Ave
rted
and
Cos
t Sav
ings
[C
uyah
oga
Cou
nty]
Academy Health, 2013
Red Carpet Care – Super-Utilizer Program
• The best approach to caring for “super-utilizers” is not known.
• With the support of health plans, BH designed a s-u program with embedded RN care coordinators, home visits, and personal phone access to the RN 24/7.
• Health plans paid for the RNs, pmpm, and agreed to a shared-savings program.
• We asked whether the Red Carpet Care program reduced costs.
Estimated Savings in Total Costs of Care, per person, per year ($)
(MEDICAL MUTUAL)
• Difference = $4,734.36 pppy (394.53 pmpm) • Across 67 RCC patients, one year savings were
$317,200.
The MetroHealth System
Red Carpet Care (RCC) Enrollees (n = 67)
Control Patients (n = 44)
REDUCTION, per person, per
year $ 5,098.56 $ 364.20
MetroHealth Care Plus (MHCP) – a Medicaid waiver program in 2013
• Anticipating Medicaid expansion while debate about its demise continued, Ohio received a waiver to test an expansion in Cuyahoga County starting February 4, 2013
• 28,295 uninsured poor patients enrolled, with a median enrollment period of 9 months
• We re-purposed Better Health’s data to determine whether quality increased at lower costs among the enrollees vs. the continuously uninsured.
Features of MetroHealth Care Plus • Waiver conditions
– Closed panel care, 3 unaffiliated safety nets
– Accept risk of exceeding CMS expenditure cap
– No co-pays
• Prepared safety net orgs – committed to disadvantaged pops,
QI, transparency – All practices recognized PCMH – Mature users of EHRs+HIE – All members of Better Health
Cost: 28.7% ($167.36 per member-month) below federal expenditure cap, or $41M across all enrollees.
13.2
8.4
2.8 0
2
4
6
8
10
12
14
Diabetes Care Diabetes Outcomes Hypertension Control
Impr
ovem
ent i
n M
H C
are
Plus
min
us
Impr
ovem
ent i
n U
nins
ured
(in
% p
oint
s)
Difference in Differences Estimates
MHCP Results after 9 months enrollment: better care, better outcomes, savings
(Percentage points favoring MHCP enrollees)
Employer-motivated PCMH and transparency
• Three large self-insured employers wanted the best care for their employees. – They agreed to jointly support embedded
care coordinators in exchange for clinics achieving national PCMH recognition and publicly reporting their results.
• Did this unique arrangement work?
October 10, 2014 – “Kick-off” 11 Lake practices had won national recognition
for PCMH; now reporting with Better Health
Cost of Care Projects/Analyses
1. The Better Health Experiment – reduced preventable hospitalizations and related costs.
2. The Red Carpet Care program – reduced TCOC among “super utilizers”.
3. MetroHealth Care Plus – improved quality of care and saved (CMS) $41M.
4. “Primary Care Push” – Lake Health providers recognized for patient-centered care; publicly reporting and using employers’ support for care coordination
Better Health’s Triple Aim Approaches and Results
1. Approaches: Using data to identify and disseminate best practices for important conditions
• “Positive deviants” celebrated, their work disseminated
2. Results: Widely recognized improvement: • Care for adults with chronic conditions • Disparities in care across multiple dimensions • Preventable hospitalizations
Better Health’s New Initiative Children’s Health and Health Care
“Just as the twig is bent the tree’s inclined.”
– Alexander Pope (1732) Epistles to Several Persons
Childhood Asthma
Asthma care and outcomes are on Ohio’s radar
HAVE YOU RECEIVED A REPORT LIKE THIS?
Childhood Obesity
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Clinical Care - Not the Primary Determinant of Health
Clinical Care
Underlying Determinants of Health
Only 20%!
50%
Can EHRs Help with “Social Determinants”?
• We have documented patients cared for in EHR systems do better and improve faster
• This is Not true for obesity • Adult BMI levels have remained flat over Sme • All of our partners care, but none has solved the problem • How can EHRs help?
Value of EHRs in addressing “social determinants”
• EHRs can identify: • where patients live • whether they are obese, have asthma, etc • related conditions and risk factors • local resources to help
• EHRs also can: • catalyze place-based interventions
• e.g. REC centers, museums, parks, businesses, grocery stores, assessments of at-risk houuseholds…..
• help us monitor progress
Proximity of Municipal Rec Centers to our Patients
8,930 Metro adults with diabetes:
Cuyahoga County, Ohio 65% obese (BMI>30)
White Black
Hispanic Other
Our Overweight and Obese Children Can use nearby resources
30,425 – ages 2-18 4,869 - overweight (BMI 85-94 %ile) 5,870 – obese (BMI > 95 %ile) 35.2% - obese or overweight
Obese Overweight
Health Care Near Our Children’s Schools Can help us intervene early
Children’s Health and Health Care What Better Health has done to date
• Committed to the Initiative: Board of Directors, Leadership Team, Clinical Advisory Committee (CAC)
• Established CAC Children’s Sub-Committee • Consensus support for asthma and obesity
• Begun to recruit independent Pediatricians, Children’s Hospitals, and Pediatricians in large systems
• Embarked upon a multi-sector environmental scan of interest and ongoing activities
• Met twice with leaders of Institute of Medicine “CEO Innovation Collaborative” to support Cleveland
How Better Health will help
• Expand our established “backbone organization” activities in adult conditions to children: measurement, reporting, learning collaboratives, practice coaching (PCMH etc)
• Serve as convener across providers, public health agencies, state and local policymakers, and other stakeholders for children’s health
• Establish a Community Resource Database and website for use by providers and the public • Linking providers – through their EHRs - to resources near where
their patients live
www.betterhealthpartnership.org
How Can You Help?