HBCH – Local HealthSystem Strategies
Shawn Griffin, MDChief Quality and Informatics
Officer, MHMDOctober 8, 2015
Major Trends
• Houston Price Pressures Increasing• Health Systems Expanding Into Growing
Markets• Payer, System, and Group Consolidation
Changing Existing Relationships• Accountable Care Organizations Growing,
but Not All Systems Buying In• Primary Care Affiliations Expanding
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Traditional Healthcare –A Flawed ModelHow the industry has functioned
Physicians, hospitals, and insurers working insilos
Lack of data sharing across the functions thattouch the patient
Billboard Medicine - Management of a singleoccurrence, not the population
Patient engaged after becoming sick
Inadequate transparency and access to data
Lack of population management tools andcomprehensive data
Misaligned incentives between providers andinsurers
Disease and care management only aninsurer function
Little focus on systemic improvement
How it will have to function Willingness to depart from old models and
change roles of key players
New technologies enable data flows to allproviders wherever the patient presents
Focus on population health, prevention, andthe patient outside the health care setting
Proactive patient engagement
Transparent sharing of data among providersand between providers and insurer
Population management tools employed andinformed by data to give 360o view
Aligned incentives reward providers andhospitals for improved quality and cost
Providers and insurer collaborate on disease& care management to maximize impact
Investment in continuous improvement
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Accountable Care =Healthier Population
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QUALITY
COST
Doesn’t that soundsimple?
Doesn’t that soundsimple?
Evidence-based Utilization
A Very Basic Premise
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HospitalsHospitals
MHMD MHHS
PhysiciansPhysicians
Houston Landscape
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Physicians Hospitals AmbulatoryNetwork
Post Acute
Who you contract with “commoditizes” other parts.Who you contract with “commoditizes” other parts.
ACCOUNTABLE CARE ORGANIZATIONACCOUNTABLE CARE ORGANIZATION
Multi-specialtyGroups
Multi-specialtyGroups
MedicareAdvantage
Plans
Payers
HospitalSystems
HospitalSystems
MedicareAdvantage
Plans
How will we get there?
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EducationCultural ChangeAligned IncentivesOrganizational StructureCommitment to Evidence Based Medicine Information
EducationCultural ChangeAligned IncentivesOrganizational StructureCommitment to Evidence Based Medicine Information
We Started Many Years Ago…
5 Key Strategic Inflection Points Clinical Programs Committees (CPCs) (2000) Clinical Integration (2005) The Physician Compact (2008) The Patient-Centered Medical Home
(PCMH)(2011) The Accountable Care Organization (ACO)
and Single Signature (2012)
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Organization Timeline2010 20142000 2004 20122002 2006 2008 20112001 2005 20132003 2007 2009
FTC Consent Order
PQRI reporting
Order Sets
Crimson DevelopmentDiscovery of CI
Commitment to eCW
Data Analyst, Humana CI ContractBoard Restructure, MSSP ACO
CQIO, MHealth CI Contract
CPC Restructure, IPA PartnershipOrder Set Delegation
CI Bonus $
CI Bonus $
IPQS
CPRM, NCQA Certifications
MHMD Care Management
CI Bonus $Aetna ACO Contract
BCBS ACO ContractPediatric APP Contracts
Network Management
POC, APCP Contracts
Region MeetingsSupportive Medicine
Strategic Analytics, ScheduleNow
DocbookMDReferral Center, Life In Balance
ACO Service Line ProjectsCI Bonus $
MSSP Bonus$
CompactCompact
CPCsCPCs
MH ACOMH ACO
PCMHPCMH
CPCsClinicalIntegrationClinicalIntegration
Authority of the CPCs
Delegation from the health system Protocols (creating and measuring EBM practices and order set
templates)
Performance (setting and monitoring progress against establishedquality standards and protocols)
Products (drives the standardization of vendors, formularies, supplychain decisions)
Payment (Pay for performance goals, co-management agreements,ACO project metrics, PCMH elements)
Projects (ED to ED transfer policy, CT scanning in pediatric headtrauma, standardized order sets in Observation units, serviceline, credentialing and privileging standards)
Program Rationalization (Consolidation and concentration of clinicalservice delivery – i.e. open heart and joint programs)
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Iatrogenic Pneumothorax
MH SoutheastHospitalMH Southeast hospital
20 MonthsZero Iatrogenic Pneumothorax
Ultrasound MandatoryUltrasound Mandatory
MH SoutheastHospitalMH Southeast hospital
20 MonthsZero Iatrogenic Pneumothorax
Ultrasound Mandatory
514 CPCRecommendations
in 2014
Clinical Integration (2005)
Participating physicians must participate• Selecting quality measures• Reporting performance• Determining performance targets (setting realistic
goals)• Participate in committee work, performance
feedback, and quality improvement activities• Time, effort and IT infrastructure all required
Those who do not participate even afterremediation, must be removed!
MHMD Compact
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BUT WHAT WAS MISSING?WHAT ABOUT OUTPATIENT?
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DiscountsLiability InsGroupPurchasing
SingleSignatureContracts
Clinical Integration | Accountable CareOrganization
Clinical Integration | Accountable CareOrganization
Physician TrainingHCC
DocumentationICD-10CMEs
MU UniversityPhysician University
Practice TransformationEMR
Point of CareNCQA
Practice Assessment
PatientAccess
Patient Portal
Pt EngagementPatient EducationPt Engagement
Patient Education
Gap ReportsAt Risk/High Risk
Physician Report Cards
Supp MedicinePost Acute
Ambulatory ICU
UC/AHRetailClinics
Care MgmtDisease Mgmt
Health CoachesPreventive Care
The Patient-CenteredMedical Home (2011)
Informed Physician Better Care Great Experience
QualityInnovation
QualityInnovation
GNEProgram
DataClaims Files
EMR data Lab Rx
Technology
Primary Care Network>350 Adult & Pedi Physicians
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West Region70 APCPs
Region Leaders – Dr. Ankur Doshi &Dr. David Reininger
SW Region76 APCPs
Region Leader – Dr. John Vanderzyl
North Region60 APCPs
Region Leader – Dr. Ken Davis
Northeast Region27 APCPs
Region Leader – Dr. Tejas Mehta
Central Region56 APCPs
Region Leader – Dr. Kevin Giglio
Southeast Region48 APCPs
Region Leaders – Dr. MaqsoodJaved & Dr. Adnan Rafiq
WHAT DID WE LEARN ABOUT OURPERFORMANCE AS A COST &QUALITY PROVIDER?
Putting Inpatient and Outpatient performancetogether when caring for whole populations…
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Memorial Hermann
13%better
18%better
11%better
8%better
Aetna Commercial DataMemorial Hermann is more efficient than the market
Houston market
Inpatient Days/ 1000
Re-admission rates
Average length of stay
ER visits / 1000
208
236
5.1%
6.0%
3.5
3.9
180
164
Favorable PerformanceMetric Trends
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by any other Name….
Accountable Care Organizations Affordable Care Act / Obamacare Population Health Clinical Integration Patient Centered Medical Homes And the ability to apply to become a
Medicare ACO participant
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Along Came Health Reform
Memorial Hermann ACO (2012)
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VA
Ps
Rat
e pe
r 1K
Ven
t Day
s
System VAPDo No Harm
Ventilator Associated Pneumonia
Source file date: 1/30/2013Generated: 1/30/2013 12:18:11 PM Reporting Months
produced by System Quality and Patient Safety
UCL = 3.50
Mean = 2.04
LCL = 0.58
UCL = 2.88
Mean = 1.23
UCL = 2.44
Mean = 0.95
UCL = 2.46
Mean = 0.64
Qtr 1Qtr
2Qtr
3Qtr
4Qtr
1Qtr
2Qtr
3Qtr
4Qtr
1Qtr
2Qtr
3Qtr
4Qtr
1Qtr
2Qtr
3Qtr
4Qtr
1Qtr
2Qtr
3Qtr
4Qtr
1Qtr
2Qtr
3Qtr
4Qtr
1Qtr
2Qtr
3Qtr
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2006 2007 2008 2009 2010 2011 2012
0.00
2.00
4.00
6.00
Allowed for collaborative aligned incentives
programs between hospital and physicians
Relaxed fraud and abuse restrictions
Provided for safe harbors
Provided exclusive single signature capabilities
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What Does an ACO Mean?
AND THE PAYERSRESPONDED TO OUR MODEL
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Covered Lives (2015)
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370,000+Covered Lives
370,000+Covered Lives
Aetna Whole Health (ACO) (26,000)Aetna Whole Health (ACO) (26,000)
Health Solutions Commercial(45,000+)
Humana Commercial (18,700)
United Medicare Advantage (8,800)
Aetna Medicare Advantage (5,800)
Aetna Commercial (85,000)Aetna Commercial (85,000)
United (45,000)*United (45,000)*
Humana Medicare Advantage (5,000)
CMS MSSP (ACO) (45,000+)
BCBS (90,000)*BCBS (90,000)*
*estimated.
Evolution of Partnerships
PhysiciansPhysicians HospitalsHospitals
MHMD MHHSHealth PlansHealth Plans
PAYERS
ARE WE MANAGING COST& IMPROVING QUALITY?
DID IT WORK?
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PARTNERING WITHEMPLOYERS
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Clinical Economics Improved
0 100 200
CT Scans and MRIs /1,000
High -Tech Radiology Visits /1,000
Impactable Surgical Bed Days /1,000
Impactable Medical Bed Days /1,000
Impactable Surgical Admits /1,000
Impactable Medical Admits /1,000
Impactable Admits /1,000
Effic
ienc
y M
etric
s
27ACO Network, YOY performance
27.1%lower
26.6%lower
28.3%lower
47.0%lower
5.7%lower
42.4%lower
47.8%lower
0%10%20%30%40%50%60%70%80%90%
100%
Asthma:Use of
appropriatemedications
Breastcancer
screening
Cervicalcancer
screening
Colorectalcancer
screening
Diabetes:Lipid profile
Diabetes:HemoglobinA1c testing
Aetna NationalAverage
Clinical Quality Improved
2014 MHMDPerformance
Better Cost and Quality forEmployers
Global Engineering and Construction Co.supporting Energy, O&G industry
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Efficiency Results TARGET RESULT DELTA“Impactable” MedicalAdmissions/1,000 55.0 16.7 69.6%
Potentially Avoidable ER Visits/1,000 95.4 65.7 31.1%
High Tech Radiology Visits/1,000 170.3 149.0 12.5%
CT Scans and MRIs/1,000 66.3 60.5 8.7%
15%lower
20%increase
Enrollment 2014
2015
Medical Costs Target
Actual
BEST IN THE COUNTRY MSSPPERFORMANCE
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MSSP Performance Year 1(18mo)
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MSSP ACO State Total Savings ACO Share
Memorial Hermann AccountableCare Organization TX $57.83 M $28.34 M
Palm Beach Accountable CareOrganization, LLC FL $39.57 M $19.34 M
Catholic Medical Partners-Accountable Care IPA, Inc. NY $27.92 M $13.68 M
Southeast Michigan AccountableCare, Inc. MI $24.68 M $12.09 M
RGV ACO Health Providers, LLC TX $20.24 M $11.90 M
ProHEALTH Accountable CareMedical Group, PLLC NY $21.91 M $10.74 M
Triad Healthcare Network, LLC NC $21.51 M $10.54 M
WellStar Health Network, LLC GA $19.88 M $9.74 M
Accountable Care Coalition ofTexas, Inc. TX $19.10 M $9.36 M
MSSP Performance Year 2(12mo)
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MSSP ACO State Total Savings ACO Share
Memorial Hermann AccountableCare Organization TX $52.93M $22.72M
Palm Beach Accountable CareOrganization, LLC FL $32.17M $14.46M
Physician Organization of MichiganACO MI $27.07M $12.08M
Oakwood ACO, LLC MI $19.07M $8.15M
Millennium ACO FL $17.49M $7.98MProHEALTH Accountable CareMedical Group, PLLC NY $17.15M $8.02M
Allcare Options, LLC FL $16.99M $6.06MQualuable Medical Professionals,LLC VA, TN $16.62M $7.41M
Accountable Care Coalition ofTexas, Inc. TX $16.04M $6.34M
What Employers Need to Do
• Expect Consolidation in Healthcare Market• Recognize that Primary Care Relationship is Key
to Health for Employees.• Push For Greater Transparency with Payers and
Conversations Directly with Providers.• “Own” Wellness and Target Benefit Design to
Reinforce Goals.• Align Incentives for Employees, Payer, and
Providers
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