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POPULATION HEALTHa health plan medical director perspective

Healthcare Financial Management Association

November 3, 2015

Marvin J. Gordon, M.D., FACGRegional Medical Director

Health Net of California

Willie Sutton

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% population - % cost

5% population generates 60% health care cost

49% catastrophic- only 1 year of high cost

40% consistently high cost – chronic disease

11% costs are in the last year of life

3Payer-Provider Partnerships: A Palliative Care Toolkit and Resource Guide, Center to Advance Palliative Care, 2014

Medical Management

Keep the well from getting sick - prevention

Handle acute illness efficiently and effectively

Manage the chronically ill

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Population Care (95% population, 40% cost)

• “Walking well” aka “young invincibles”– Healthy lifestyle (diet, exercise, substance avoidance)

– Safe lifestyle (seatbelts, bike helmets)

– Preventive medicine (chol, BP, mammogram)

– Prenatal care (no alcohol, no smoking, folic acid)

• Acute illness (flu, broken bones, gastroenteritis, UTI)

– Early intervention– Most cost effective site of care (PCP, UC)

– Contracted provider (unit cost and utilization)

– Quality care- do it right the first time5

Population Care (5% population, 60% cost)

• Catastrophic illness (trauma, burns)– Contracted quality providers

• Chronic illness/ end of life– Disease management– Case management– Transition care management– Palliative care – Hospice– Behavioral health– Pharmacy 6

Health Net Programs• State Health Program Case Mamagement• Ambulatory Case Management (vendors))• Complex Case Mamagement (vendors0 • Care transition (from the hospital)• Behavioral Health• Home infusion• Pharmacy• Disease Management (vendor)• Concurrent Review (acute and skilled nursing)• Prior authorization• High risk OB• Community resources• In Home Support Services (State Health Programs)• Palliative care• Pain management 7

Medical ManagementPopulation management (public health)

Disease prevalence (outbreaks)PreventionBroad recommendations for a healthier population

Disease managementImprovement for a specific diseaseEducation, coaching, and interventionActivationWell enough to make a differenceSick enough to make a differenceIntervention may require physician participation (e.g. CHF)

Case managementManaging the individualSocio-economic and medicalMultifactorial, co-morbidities

Transition care management

From the in-patient setting to the out-patient setting (hospital discharge)

Appts, meds, red flags, record

End of life8

Cost Containment Case Study

END OF LIFE

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Barnato, AE, et al, Medical Care, 45: 386 – 393, May, 2007

• 40% concerned about too little treatment• 45% concerned about too much treatment• 86% prefer to be at home for last days• 84% not want life prolonging drugs that

make them feel worse• 72% want symptom relief even if drugs

may shorten life• 87% would NOT want mechanical

ventilation to prolong life by 1 week• 77% would NOT want mechanical

ventilation to prolong life by 1 month

High Risk Diagnoses – Cancer -NEJMHigh Risk Diagnoses – Cancer -NEJM

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Medicare Expense in the Last 6 Months of Life Barnato, AE, et al, Medical Care, 45: 386 – 393, May, 2007

Grand Junction , CO McAllen, TX

Hosp/physician cost $8,366 $21,123

Days in ICU 1.0 5.6

Died in acute hosp 16.7% 45.1%

No correlation of cost with outcome or satisfaction

No significant correlation of cost with patient preferences

Cost is related to– More specialists– More hospitals and ICU beds– More technology

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Palliative Care

Large regional variation in “death in hospital” vs “death in home”

Death in home hospital nursing home

Oregon 35% 32% 32%National 25% 50% 25%New York 21% 62% 17%

Only 31% of late stage cancer patients had end of life discussion with oncologist

Where’s Waldo?

Spend a lot money at end of life

Regardless of patients’ wishes

Which vary by zip code

Variation based on

number of specialists

number of hospitals

amount of technology available

With physicians not discussing options with the patient

WHAT SHALL WE DO? 15

Palliative Care

• Specialized medical care for people with serious illness. This type of care is focused on providing patients with relief from symptoms, pain, and stress from the serious illness – whatever the diagnosis. The goal is to improve quality of life for both the patient and family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient’s other doctors to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness and can be provided together with curative treatment.

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Major Palliative Referral Criteria

• Utilization (using or about to use the hospital and ED to manage their condition)

• Code Status issues• Diagnosis and prognosis (progressive with 1-2

years life expectancy• Symptoms not controlled (pain, nausea and

vomiting)• Support needed (psychological, financial,

social, caregivers• High cost

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Hospice

• Terminally ill - 6 month prognosis• Comfort only, not curative• Family caregivers can get extra

support and benefitsMedicare Hospice Benefits official government booklet

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Palliative Care• Curative and supportive• Usually 12-24 month prognosis• Usually not a benefit

Palliative Care Pilot (30 referrals)

• 3 refused

• 17 from Top 1% Team; 13 from direct referral

• 67% of deaths in the home (national aver. 25.4%)

• 40% to hospice

• 53% DNR as out patient

• 80% DNR in hospital

• 74% completed POLST 19

Palliative Pilot (cont’d)

• Mean time in hospice 22.4 days (NHPCO aver. 72.6 days)

• Median time in hospice 8 days (NHPCO aver. 18.5 days)

• Average time in palliative program 22 days

• MD visits 1.5 PMPM (budget 1.0)

• RN visits 5.8 PMPM (budget 4.0)

• Phone calls 26.2 PMPM (budget 20.0)

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Opportunity Analysis Savings

• 36 acute hospital admits

• 13 acute hospital days

• 1 skilled nursing facility admit

• 730 subacute days

• 21 ambulance rises (911)

$868,053 (although 1 case saved $396,664)

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What Does the Data Tell Us?(aka “where’s the beef”)

• Highly successful on dollar savings• Referrals are late in the course of illness (hospice data,

time in palliative)- need more education/ marketing• Low volume

– 57% from claims ; more data mining – other sources e.g. LTC, dialysis, oncology, ED UM reports

– 43% real time; more marketing, education – Low volume due to limited Medicare– Only one county (? expand)

• 10% refusals – avoid the “H” word and the “P” word• Reimbursement insufficient relative to resources

consumed (contract; telemedicine) 22

Dear Willie

• Populations are heterogeneous – not all banks are the same

• Different interventions for different subpopulations – not all banks are robbed in the same way

• Can measure the value proposition – that’s why you case the bank…the “take’ better be worth the risk

• It doesn’t work for every patient, but it works most of the time – I know it’s not perfect…explains why I got caught…but I thought it was worth it 23