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Division of Population Health Management
Partners Approach to Meeting the Healthcare Cost Challenge
Timothy Ferris, MD, MPHSVP, Population Health Management, MGH, MGPO and Partners HealthCare
Nuffield Trust Health Policy Summit 2014March 6, 2014
Division of Population Health Management
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
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Division of Population Health Management
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
Challenges1. 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 environment3
Division of Population Health Management
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
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Division of Population Health Management
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://healthaffairs.org/blog/2014/01/29/accountable-care-growth-in-2014-a-look-ahead/**http://www.oliverwyman.com/media/ACO_press_release(2).pdf***http://www.acpinternist.org/archives/2013/07/acos.htm
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Division of Population Health Management
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
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Division of Population Health Management
Enhanced access to specialty services
The path we’re traveling at Partners
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Pressure to reduce cost trend
New contracts with risk for trend
Internal PerformanceFramework
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
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2
3 New relationships with community hospitals and doctors
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Division of Population Health Management
Our new contracts…almost 2 years inLives 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
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Medicaid
NHP
Population with significant disability,
mental health, and substance abuse
challenges
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Self Insured
Partners Plus
Commercial population, but savings accrue
directly to Partners, and improves our
own lives
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Covered lives: ~80kCovered lives: ~80kCovered lives: ~25KCovered lives: ~25KCovered lives: ~350KCovered lives: ~350KCovered lives: ~75kCovered lives: ~75k
Partners currently manages roughly 500,000 lives in various accountable care relationships
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Division of Population Health Management
Priority programs
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Priority Population Health Management ProgramsPrimary 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
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Virtual visits and technology tools
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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
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
Division of Population Health Management
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
CriteriaAssess
Risk
Schedule OR
Procedure Recovery Physician encounter
Possible Need for
Procedure
Shared Decision Making
Pre-Procedure
Testing
Tier 1, 2 Outcome Measures
Tier 3Outcome 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: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
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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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
**Hannan, EL, et al. Appropriateness of Diagnostic Catheterization for Suspected Coronary Artery Disease in New York State. CIRC INTERVENTIONS. January 28, 2014. 113.000741n=745
n=8986
Median hospital-level inappropriateness rate is 28.5%**
Appropriateness Scores for Diagnostic Catheterization at MGH vs. NY Cardiac Database **
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
Division of Population Health Management
What does PHM cost?
Total CostPHM 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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Division of Population Health Management
What is the ROI?
$0
$50
$100
$150
$200
$250
2015 2016 2017
Total PHM Acceleration Cost
Savings from External Risk
Savings from full IPFSavings 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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Division of Population Health Management
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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