How WellMed Reduced Health Care Costs in the Rio Grande ... · of the 4 chronic disease states (DM,...

How WellMed Reduced Health Care Costs in the Rio Grande Valley of Texas

How WellMed Reduced Health Care Costs in the Rio Grande Valley of Texas

Presented by: Presented by: Carlos O. Hernandez, MDCarlos O. Hernandez, MDPresident, WellMed Medical Group, P.A.President, WellMed Medical Group, P.A.

OverviewOverview

Rio Grande Valley health care costsWho is WellMed?WellMed’s business modelWhat drove health care cost in the Rio Grande Valley?WellMed’s strategies for successDid our strategies work?Next steps

WellMed Medical Management Internal use only. Do not copy or distribute without written permission2

Rio Grande Valley Health Care Rio Grande Valley Health Care Costs Costs -- Then and NowThen and Now

“…I’ve come to think that a major reason for the change may be a collection of primary-care doctors who don’t even seem to recognize the impact of what they’ve been doing.”

-Atul Gawunde3

http://www.newyorker.com/magazine/2015/05/11

WellMed Mission and VisionWellMed Mission and Vision

Mission: To help the sick become well and to help patients understand and control their health in a lifelong effort at wellness.

Vision: To change the face of healthcare delivery for seniors by providing quality, proactive patient care with a focus on prevention.

y

Our goal is to provide better preventive healthcare to seniorsthrough a proven measurable andresults-driven healthcare delivery system.


The WellMed DifferenceThe WellMed Difference

Dr. George M. Rapier III founded WellMed in 1990 as a single clinic in the San Antonio Medical CenterGuiding principle was to focus on the PCP-patient relationship – PCPs working to comprehensively care for our patients’ health care needs and breaking down barriers to our patients’ health issuesOver the years, WellMed grew into a diversified healthcare company with clinics, medical management, utilization management, transportation services, and an award winning Disease Management program


WellMed at a GlanceWellMed at a Glance


What We AreWhat We Are

WellMed is a healthcare delivery system serving seniors in a primary care-centered environment through a comprehensive network of contracted and employed physicians and multiple Medicare Advantage Health Plans.

WellMed Medical Management Inc. MSO

WellMed Medical Group PA Physician Organization

WellMed Network Inc. Risk-bearing 501a


The WellMed Business ModelThe WellMed Business Model

Mutually Beneficial Relationships with PCPs

High Quality Medical Care Focusing on access, care coordination and care delivery resulting in lower health costs

Shifts away from traditional acute and episodic care to a chronic care delivery model

We believe the highest quality medical care yields lowest costs by removing healthcare expenses from the system over time.


The Rio Grande Valley (RGV) of The Rio Grande Valley (RGV) of Texas Texas -- Six Years AgoSix Years Ago

Dr. Atul Gawande – “The Cost Conundrum”, The New Yorker, June 2009

Cost of Care in McAllen, Texas compared to El Paso, Texas

Medicare spent $15K per enrollee in 2006 -2X national averageEl Paso County (800 miles from McAllen) - Generally same demographics half the per-capita Medicare costs and the same or better results

UtilizationMedicare Patients in McAllen received 2-3X pacemakers, CABG’s, stentsHome health was 5X El Paso costs


Utilization compared to El PasoAlmost 50% more specialist visits for critically ill Medicare patients

2/3 more likely to see 10+ specialists in a 6 month period

Medicare Patients in McAllen received20% more abdominal ultrasounds200% nerve-conduction studies to diagnose carpal tunnel syndrome2-3X pacemakers, CABG’s, stents

Home health was 5X El Paso costs

The Rio Grande Valley (RGV) of The Rio Grande Valley (RGV) of Texas Texas -- Six Years AgoSix Years Ago


Misaligned Incentives Drove CostsMisaligned Incentives Drove Costs

Doctors were rewarded in a Fee for Service model so the focus was on QUANTITY of care delivered

Some doctors owned a stake in hospitals, home health agencies, imaging centers, and other designated health services

Doctors incented to over-utilize and over- treat patients with minimal perceived threat of penalties for this behavior


WellMed entered the RGV in 2009WellMed entered the RGV in 2009

WellMed entered the market in a value- based payment model (an alternative to fee- for-service)

WellMed partnered with select health plans to accept full-risk capitation payments for senior and dual-eligible patients

WellMed Networks, Inc. contracted with various specialists, home health and hospitals in the region

Acquired the first clinic in the RGV in 2009 WellMed Medical Management Internal use only. Do

not copy or distribute without written permission12

Medicare Population RGVMedicare Population RGV Three Select CountiesThree Select Counties

State Name County Name Eligibles Enrolled Penetration

Texas

Cameron 55,158 20,652 37.44%

Hidalgo 90,254 30,983 34.33%

Willacy 3,309 1,122 33.91%Jan 2015 Total 148,721 52,757 35.47%


Key Strategies to WellMedKey Strategies to WellMed’’s s SuccessSuccess

•

Care Management/Care Coordination

•

Quality

•

Risk Adjustment

•

Growth

•

Provider and Patient Engagement

•

Systems approach to care


What is Care Management?


Disease Management ProgramsDisease Management Programs DelegatedDelegated

•

Patients who have one of the following chronic conditions are eligible to enroll in the Disease Management Programs


Care Coordination Team

17

Advanced Care Management Program

Advanced Care Management Advanced Care Management ProgramProgram

•

Care Management for High Risk/Complex Patients- top 3-5% of high risk population (Home Based Care/Palliative Care)

•

Telephonic & Face to Face Assessment & Monitoring

•

Transitions Program

•

Clinic Based Patient Care Conferences (PCC)


Percent of Population

Percent of Cost

PMPM Cost

Illness Burden Range

78% of admissions

were for members in

bands 1 and 2

Illness Pyramid – The Rosetta Stone

Source: CareFirst HealthCare Analytics – 2012 Data

Advanced/ CriticalIllness

BAND 1

20

Population Stratification Bands

Clinic Based Care TeamBAND 1

At Risk BAND 3At Risk BAND 3

High RiskBAND 4High RiskBAND 4

Advance IllnessBAND 5

Advance IllnessBAND 5

●

Homebound●

Hospice appropriate –not willing to enroll●

Life limiting illness with possible life expectancy <12-24 months

●

Requires Symptom Management●

Metastatic Malignancy●

CHF stages IV-V●

End stage COPD, Cirrhosis

●

>2 admissions in last 6 months ●

S/P MI within 60 days●

AIDS ●

CHF stage III ●

ESRD-

temporary catheter ●

Hospice graduates ●

Cancer-

active chemo treatment (Rounds 1 &2)●

Change in Functional Status (Amputation , CVA)●

Poly-Pharmacy and poor compliance (> 8 prescription meds)●

Home Health greater than 2 months●

Multiple ER visits within 3-6 months●

Moderate to severe dementia●Requires short term case management assistance●

Oxygen Dependent ●

S/P transplant to 1yr after transplant●

Hip fracture > age 75

●

Transplants (evaluation stage through transplant)●

Co-occurring Medical and Mental Conditions such as Bipolar disorder, schizophrenia and major depression (mental health dx plus any one of the 4 chronic disease states (DM, IHD, CHF, COPD, PVD)

●

ESRD -fistula●

High Cost Injectables●

HIV●

>85 & lives alone●

Cancer-

active chemo treatment (Round 3+)●

Other conditions or situations deemed by PCP●

1 unplanned admission in 6 months●

Frequent falls greater than 2 in a 3 month period

●

Health & Wellness●

Preventive Screening●

Annual Care Visits

BAND 2Clinic Based Team and Care

Management

BAND 2Clinic Based Team and Care

Management

Disease Management Programs●

SNP members●

Controlled/Stable CHF ●

Controlled/Stable COPD/Asthma●

Controlled/Stable Diabetes●

Controlled/Stable IHD/HTNUtilization Management●

Observation Admissions●

Elective Admissions ●

ER Visit

Care Management Across All Care Management Across All SettingsSettings


Transitions Program

Transitions Program GoalsTransitions Program Goals

•

Decrease Readmissions/ER Visits

•

Facilitate Safe Transition to Home

•

Coordination of Services (medication reconciliation, team communication, and close follow up)

•

Meet SNP Requirements (Special Needs Plan) and HEDIS quality goals


ClinicClinic--based Population Managementbased Population Management-- Patient Care Coordination MeetingsPatient Care Coordination Meetings

•

Weekly Meeting with Health Care Team

•

Review Inpatient Transitions and ER visits

•

Review Complex Care Cases/risk stratification of population

•

Develop/Revise Plan of Care

•

Opportunity for process improvement


Provider EngagementProvider Engagement

•

Intrinsic rewards–

Autonomy, mastery, purpose, tradition

•

Extrinsic rewards–

Incentives

–

Comparative reporting–

Personal development


Did it work?Did it work?Rio Grande Valley – Historic Utilization MetricsDates of Service: Jan 2009 - March 2015


Rio Grande Valley – Historic Utilization Metrics RAF AdjustedDates of Service: Jan 2009 - March 2015-Risk adjusted

Did it work?Did it work?






Next StepsNext Steps……

The work of improving is never done!Specialty compacts

Volume steerage

Patient engagementPatient portal

Technology


Engaging the Physicians Engaging the Physicians and Healthcare Teamand Healthcare Team

Incentives based on:Health care costsQualityOutcomesRisk adjustment coding accuracyPatient satisfactionMembership/MA panel sizeProvider behavior/core values


Physician IncentivesPhysician Incentives

HCC PMPM Qtrly Pool Base

Line

Q4 HCC PMPM % RELATIVE TO PAYOUT Q4 HCC PMPM

Q4 Final HCCPayout

QUALITY % RELATIVE TO PAYOUT Quality

FOCUS ON CARE % RELATIVE TO PAYOUT

FOCUS ON CARE

HCC % RELATIVE TO PAYOUT HCC%

MEMBERSHIP SCORE 2/2015

12/2014 EVALUATION SCORES

Proposed Bonus With Multipliers

6,875.00 42.49% 2,921.18 2,921.18 99.46% 6,216.06 95.13% 1,189.08 99.87% 3,744.97 1.10 1.00 14,774.86

6,875.00 114.79% 7,891.72 7,891.72 88.83% 5,552.16 95.28% 1,191.05 99.72% 3,739.63 1.00 1.00 18,374.56

6,875.00 114.79% 7,891.72 7,891.72 82.97% 5,185.59 90.54% 1,131.77 99.83% 3,743.45 1.10 1.00 18,850.17

6,875.00 103.49% 7,114.61 9,114.61 100.00% 6,250.00 100.00% 1,250.00 100.00% 3,750.00 1.00 1.18 22,197.42

2,291.67 103.49% 2,371.54 2,371.54 71.09% 1,480.98 95.46% 1,193.20 98.97% 3,711.28 1.00 1.00 8,757.01

6,875.00 107.34% 7,379.94 7,379.94 80.41% 5,025.39 90.51% 1,131.39 98.99% 3,712.17 1.20 1.00 18,973.78

6,875.00 124.15% 8,535.06 10,535.06 84.75% 5,296.92 92.87% 1,160.82 99.57% 3,733.85 1.10 1.14 23,213.84

1,527.78 28.48% 435.11 1,435.11 91.27% 1,584.51 75.66% 788.17 99.59% 3,112.11 1.10 1.00 7,265.89

2,291.67 112.54% 2,579.15 2,579.15 61.00% 1,270.77 90.75% 1,134.42 98.45% 3,691.77 1.10 1.00 9,109.91

6,875.00 28.48% 1,957.70 1,957.70 94.81% 5,925.52 90.00% 1,125.03 99.71% 3,739.30 1.00 1.00 12,747.55

54,236.11$ 49,077.73$ 54,077.73$ 43,787.91$ 11,294.93$ 36,678.52$ 154,264.99$

458.33 42.49% 194.75 294.75 100.00% 208.33 97.34% 121.67 100.00% 375.00 1.00 1.00 999.75

2,062.50 42.49% 876.35 876.35 100.00% 1,875.00 97.34% 365.02 100.00% 1,125.00 1.00 1.00 4,241.37

687.50 114.79% 789.17 789.17 86.37% 539.82 95.07% 356.52 99.91% 1,123.97 1.00 1.00 2,809.48

687.50 114.79% 789.17 1,039.17 86.37% 539.82 95.07% 356.52 99.91% 1,123.97 1.00 1.00 3,059.48

458.33 103.49% 474.31 724.31 86.01% 179.19 100.00% 125.00 99.10% 371.63 1.00 1.00 1,400.12

687.50 103.49% 711.46 961.46 86.01% 537.57 100.00% 375.00 99.10% 1,114.88 1.00 1.00 2,988.91

2,062.50 107.34% 2,213.98 1,713.98 80.85% 1,515.85 97.34% 365.02 99.12% 1,115.15 1.20 0.80 4,709.99

2,062.50 124.15% 2,560.52 2,560.52 85.21% 1,597.75 95.02% 356.34 99.70% 1,121.66 1.00 1.14 6,030.81

2,062.50 28.48% 587.31 787.31 95.33% 1,787.36 92.09% 345.36 99.85% 1,123.30 1.00 1.00 4,043.32

11,229.17$ 9,197.02$ 9,747.02$ 8,780.68$ 2,766.45$ 8,594.54$ 30,283.23$

65,465.28$ 58,274.76$ 63,824.76$ 52,568.59$ 14,061.38$ 45,273.05$ 184,548.22$



Success Success -- Three KeysThree Keys

Patient Stratification

Transitions Program

Access to Care


SummarySummary

Rio Grande Valley health care costs then & nowWellMed’s business modelHealth care cost in the Rio Grande Valley driven

by misaligned incentivesWellMed’s strategies for successOur systems approach to care drove costs downWellMed is not done yet….still striving to

improve care to our patients while driving cost down where appropriate


Questions?Questions?


ReferencesReferences

Gawande, A. (2009, June 1). The Cost Conundrum - The New Yorker. http://www.newyorker.com/magazine/2009/06/01/the-cost- conundrum

Gawande, A. (2009, June 23). The Cost Conundrum Redux - The New Yorker. http://www.newyorker.com/news/news-desk/atul- gawande-the-cost-conundrum-redux

Gawande, A. (2015, May 11). America's Epidemic of Unnecessary Care. http://www.newyorker.com/magazine/2015/05/11/overkill- atul-gawande


http://www.newyorker.com/magazine/2009/06/01/the-cost-conundrum



http://www.newyorker.com/news/news-desk/atul-gawande-the-cost-conundrum-redux



http://www.newyorker.com/magazine/2015/05/11/overkill-atul-gawande



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How WellMed Reduced Health Care Costs in the Rio Grande ... · of the 4 chronic disease states (DM,...

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