Copyright © 2008, Intel Corporation. All rights reserved.

Care Beyond the Hospital: Partnership for the Future: HIT, Clinical informatics and CV care

Dr. Mark BlattDr. Mark BlattDirector Director Healthcare Industry SolutionsHealthcare Industry SolutionsDigital Health Group, IntelDigital Health Group, Intel

Independent Living

Connected Healthcare

Intel’s Digital Health Focus Areas

Chronic Disease

Management

Research & InnovationPolicy & Standards

Explore how people deal with specific healthcare problems

Observe people in their own environments to assess unmet needs--on top of market research

Study

Understand

Design prototypes of new technology solutions

Develop

Field-test prototypes in everyday settings, everyday lives

Pilot

Turn prototypes into new platforms that meet people’s needs

Deliver

Research and Innovation

Intel social science fieldwork in more than1000 homes, 100 clinics, 20 countries, 12 pilots

Recurring Themes

Social Connectedness

Patient EmpowermentBehavioral Change

PRI Video

Four Functional Areas for Home Telecare

• Chronic Disease management: stable pts

– Reduce direct FTF engagements: manage at home

• ED diversion: Hospital@Home (acute exacerbations)

– Discharge select pts to homecare from ED

• Reduce ALOS

– Earlier discharges

• Avoided readmissions– Care coordination

Evaluating the evidence base for the use of home telehealth remote monitoring in elderly with heart

failure

• Evaluating the evidence base for the use of home telehealth remote monitoring in elderly with heart failure Telemed J E Health. 2009 Oct;15(8):783-96. Dang S, Dimmick S, Kelkar G.

• Extended Care and Research Services, Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, Florida 33125, USA. stuti.dang@va.gov

• Information and communication technology offers promise for better coordination of care for patients with congestive heart failure (CHF). MEDLINE, EMBASE, and CINHAL databases were searched for evidence on remote monitoring of patients with heart failure (HF). The search was restricted to randomized controlled trials using either automated monitoring of signs and symptoms or automated physiologic monitoring. For this review, telephone-based monitoring of signs and symptoms was not considered remote monitoring. Studies were also excluded if they did not present outcomes related to healthcare utilization.

• Nine studies met selection criteria, with interventions that varied greatly. Four three-arm studies directly compared the effectiveness of two different interventions to usual care.

• Six of the nine studies suggested a 27%-40% reduction in overall admissions. Two two-arm studies demonstrated a 40%-46% reduction in HF-related admissions while two other three-arm studies showed similar trends; however, this was not statistically significant. Three of nine studies suggested a significant reduction in mortality (30%-67%) and three studies showed significant reduction in healthcare utilization costs.

• Two studies suggested a 53%-62% reduction in bed days of care. • Two studies showed significant reduction in the number of Emergency Department visits.

Three two-arm studies and one three-arm study demonstrated significant overall improvement in outcomes with use of telemonitoring. Available data suggest that telemonitoring is a promising strategy. More data are needed to determine the ideal patient population, technology, and parameters, frequency and duration of telemonitoring, and the exact combination of case management and close monitoring that would assure consistent and improved outcomes with cost reductions in HF

Telemonitoring or structured telephone support programmes for patients with chronic heart failure:

systematic review and meta-analysis

• BMJ. 2007 May 5;334(7600):942. Epub 2007 Apr 10.• Clark RA, Inglis SC, McAlister FA, Cleland JG, Stewart S.• Division of Health Sciences, University of South Australia, Adelaide, Australia.• Comment in: • BMJ. 2007 May 5;334(7600):910-1. • Nat Clin Pract Cardiovasc Med. 2007 Nov;4(11):588-9. • OBJECTIVE: To determine whether remote monitoring (structured telephone support or

telemonitoring) without regular clinic or home visits improves outcomes for patients with chronic heart failure. DATA SOURCES: 15 electronic databases, hand searches of previous studies, and contact with authors and experts. DATA EXTRACTION: Two investigators independently screened the results. REVIEW METHODS: Published randomised controlled trials comparing remote monitoring programmes with usual care in patients with chronic heart failure managed within the community.

• RESULTS: 14 randomised controlled trials (4264 patients) of remote monitoring met the inclusion criteria: four evaluated telemonitoring, nine evaluated structured telephone support, and one evaluated both. Remote monitoring programmes reduced the rates of admission to hospital for chronic heart failure by 21% (95% confidence interval 11% to 31%) and all cause mortality by 20% (8% to 31%); of the six trials evaluating health related quality of life three reported significant benefits with remote monitoring, and of the four studies examining healthcare costs with structured telephone support three reported reduced cost and one no effect.

• CONCLUSION: Programmes for chronic heart failure that include remote monitoring have a positive effect on clinical outcomes in community dwelling patients with chronic heart failure.

Applying research evidence to optimize telehomecare

• .School of Nursing, University of Pennsylvania, 420 Guardian Drive, Philadelphia, PA 19104-6096, USA. bowles@nursing.upenn.edu Bowles KH, Baugh AC

• Telemedicine is the use of technology to provide healthcare over a distance. Telehomecare, a form of telemedicine based in the patient's home, is a communication and clinical information system that enables the interaction of voice, video, and health-related data using ordinary telephone lines. Most home care agencies are adopting telehomecare to assist with the care of the growing population of chronically ill adults. This article presents a summary and critique of the published empirical evidence about the effects of telehomecare on older adult patients with chronic illness. The knowledge gained will be applied in a discussion regarding telehomecare optimization and areas for future research. The referenced literature in PubMed, MEDLINE, CDSR, ACP Journal Club, DARE, CCTR, and CINAHL databases was searched for the years 1995-2005 using the keywords "telehomecare" and "telemedicine," and limited to primary research and studies in English. Approximately 40 articles were reviewed. Articles were selected if telehealth technology with peripheral medical devices was used to deliver home care for adult patients with chronic illness. Studies where the intervention consisted of only telephone calls or did not involve video or in-person nurse contact in the home were excluded. Nineteen studies described the effects of telehomecare on adult patients, chronic illness outcomes, providers, and costs of care. Patients and providers were accepting of the technology and it appears to have positive effects on chronic illness outcomes such as self-management, rehospitalizations, and length of stay.

• Overall, due to savings from healthcare utilization and travel, telehomecare appears to reduce healthcare costs. Generally, studies have small sample sizes with diverse types and doses of telehomecare intervention for a select few chronic illnesses; most commonly heart failure.

• Very few published studies have explored the cost or quality implications since the change in home care reimbursement to prospective payment.

• Further research is needed to clarify how telehomecare can be used to maximize its benefits among diverse adult chronic illness populations

Commercial ambulatory EHRs may not improve care coordination between patients, clinicians

.

Modern Healthcare (12/30, Lubell) reports, "Commercial electronic health records are falling short in some areas to improve care coordination between patients and clinicians," according to a study appearing online in the Journal of General Internal Medicine. Researchers found that commercial ambulatory care EHRs "are less helpful for exchanging information across physician practices and care settings." The study noted that EHRs may create "information overload that complicates providers' efforts to discern key clinical information."

Intel Confidential

Better information

leads totargeted care

Engagingexperienceimproves

compliance

Patient educationleads to positivebehavior change

Easy access toinformation for

all leads tobetter outcomes

Benefits 1

• Deliver accurate, relevant, and timely information to all members of the care team

Telehealth and Telecare Technologies Goals

ImproveChronic Disease

Management

ReduceCostly

Complications

Integrated Systems Technologies

PatientActive

Involvement

• Give patients an intuitive, enjoyable, and educational means of communication with their care team

• Provide self-management tools for patients to take a more active role in their own care

• Offer communication tools that connect the patient's entire care team for better coordination of care

Features for Success

1. Refer to speaker notes for references and source.

Vitals Collection Educational Content and Tools

Telehealth Technologies Today

Communication

Monitors

MessagingIVR FaxVideoConferencing Telephone Mail

PersonalDiaries

Self MgmtTool Videos Lifestyle

Guidance

Intel Confidential

Monitor and manage standard vital signs

Evolution Toward Personal Health Systems

Information Sharing

Independence1

Connection to healthcare advice

Safe and friendly environment

Friendly check-in mechanisms

Connection to friends and caregivers

Monitor standard vital signs

Data-rich health management systems

Qu

ality

of

Care

an

d S

ocia

l C

on

necti

on

ISOLATED VITAL COLLECTION AND ONE-WAY COMMUNICATIONISOLATED EDUCATIONL CONTENT

REAL-TIME TWO-WAY COMMUNICATION. INFORMATION GATHERING AND

INTEGRATED EDUCATIONAL TOOLS

Patient communication

Education content and Tools

Education content and Tools

1. Refer to Intended Use – See notes

Possible Business Models for Healthcare

Delivery Reform

Mark Blatt MD

Director Healthcare Industry Solutions

Intel, Digital Health Groups

Models of Care to Consider

• Patient Centered Medical home (PCMH)

• Independence at Home Act (IAH)

• Post discharge 30 days Bundles

• Accountable Care Organizations (ACOs)

General theme: Treat citizens in lower cost settings and when possible keep them there

New World Order: How Providers Might be Effected

• Your Investment Portfolio which funds your capital budgets has been diminished

• Giving Campaigns that supplemented the budgets have shrunk • Credit markets are much harder to access • You now have to fund for capital budgets from operational income

• Mr. Obama has announced $ 340B in planned spending cuts for Medicare, Medicaid and Home Health over the next 10 years

• The Administration is also targeting Recidivism and 30 day readmissions

The Costs: Chronic Conditions in the Medicare Population

Number of Conditions

E/M Visits per Year

% of Medicare

Population

Visits x Medicare

%

Weighted Average

Medicare Pts. With 1 Condition

3.5 0.173 0.210976 0.738415

Medicare Pts. With 2 Conditions

5.7 0.218 0.265854 1.515366

Medicare Pts. With 3 Conditions

7.9 0.188 0.229268 1.81122

Medicare Pts. With 4 Conditions

9.4 0.241 0.293902 2.762683

Average # of Medicare Visits

0.82 6.827683

Source: Agency for Healthcare Research and Quality. Medical Expenditure Panel Survey. 2001. Cited by Anderson G, Herbert R, Zeffiro T, and Johnson N, for the Partnership for Solutions. Chronic Conditions: Making the case for ongoing care. September 2004 Update. Available at: http://www.partnershipforsolutions.org/DMS/files/chronicbook2004.pdf. Accessed January 23, 2008.

Why Payment Reform is Needed

We don’t do a great job of caring for those with Chronic diseases

• Medicare beneficiaries with multiple chronic illnesses see an average of 13 different physicians

• Fill 50 different prescriptions a year

• Account for 76% of all hospital admissions

• Account for 88% of all prescriptions filled

• Account for 72% of physician visits

• And are 100 times more likely to have a preventable hospitalization than someone with no chronic conditions

Testimony of Gerard F. Anderson, Ph.D., Johns Hopkins Bloomberg School of Public Health, Health Policy and Management, before the Senate Special Committee on Aging, “The Future of Medicare: Recognizing the Need for Chronic Care Coordination, Serial No. 110-7, pp. 19-20 (May 9, 2007).

CPTs Already Exist for Other Than In-person Care

Anticoagulant Management (CPT Codes 99363 and 99364)

Medical Team Conference (CPT Codes 99366-99368)

Care Plan Oversight (99339-99340; 99374-99380)

Counseling Services (99401-99420)

Telephone Services (99441-99443; 98966-98968)

Online Medical Evaluation (99444; 98969)

Education and Training for Patient Self-management (98960-98962; 99078)

Review of Data / Preparation of Special Reports (99080, 99090, 99091)

Medication Therapy Management Services (99605-99607)

The Patient-Centered Medical Home (PCMH) is a Model of Health Care Delivery• The PCMH is built upon the documented value of primary care in achieving better health

outcomes, higher patient experience, and more efficient use of resources. Patients who receive care from a PCMH have continuous access to a personal physician who provides comprehensive and coordinated care for the large majority of their health care needs (from Institute of Medicine definition of primary care).

• The PCMH would be responsible for all of the patients’ health care needs: acute care, chronic care, preventive services, and end of life care working with teams of health care professionals. The PCMH would coordinate the care of its patients with specialists, lab/x-ray facilities, hospitals, home care agencies, and all other health care professionals on the patient care team.

• The PCMH would adopt the principles of patient-centeredness: allowing patients free choice of physician, providing prompt appointments, reducing waiting times, delivering care based on the best evidence on clinical effectiveness, empowering patients to partner with their personal physicians on decision-making, and providing care in a culturally and linguistically appropriate manner.

• The PCMH would use health information systems to provide data and reminder prompts such that all patients receive needed services.

Source: Patient Centered Primary Care Collaborative 2008 www.pcpcc.net

PCMH Pilot Map

• UnitedHealth Group PCMH Demonstration• Program (AZ)• Colorado Multi-Stakeholder Multi-State• PCMH Pilot (CO)• Wellstar Health System (GA)• Quality Quest Medical Home (IL)• Louisiana Health Care Quality Forum

Medical Home Initiative (LA)• Maine Multi-Payer Patient-Centered

Medical Home Pilot (ME)• Aligning PCMH Stakeholders in Michigan

(MI)• Blue Cross Blue Shield of Michigan

Physician Group Incentive Program (PGIP) (MI)

• CIGNA and Dartmouth-Hitchcock Patient-Centered Medical Home Pilot (NH)

• NH Multi-Stakeholder Medical Home Pilot (NH)

• Patient-Centered Medical Home—Diabetes Management (ND)

• MediQhome Quality Project: Patient-Centered

• Advanced Medical Home Quality Improvement Initiative (ND)

• CDPHP Patient-Centered Medical Home Pilot (NY)

• Emblem Health Medical Home High Value Network Project (NY)

• New York Hudson Valley p4p/Medical Home Project (NY)

• Cincinnati Medical Home Pilot Initiative (OH)

• Greater Cincinnati Aligning Forces for Quality Medical Home Pilot (OH)

• Southeastern Pennsylvania Rollout of the Chronic Care Initiative (PA)

• Rhode Island Chronic Care Sustainability Initiative (CSI-RI) (RI)

• Memphis Multi-Payer Patient-Centered Medical Home (TN)

• Texas Patient-Centered Medical Home Demonstration Project (TX)

• Patient-Centered Medical Home—Vermont (VT)

Source: Patient Centered Primary Care Collaborative 2008 www.pcpcc.net

Payment Models: PCMH

• Three Tiered Reimbursement Methodology consistent with the Joint Principles of Patient-Centered Medical1

• Home: FFS, Care Management Fee which increases with higher levels of NCQA PPC-PCMH achievement1

• Payment begins at Level I1

• PMPM payment based upon potential savings1

• Monthly Care Management Fee plus performance bonus1

• DM fee allowed on an annual basis and sharing of demonstrated cost savings1

1 Source: Patient Centered Primary Care Collaborative 2008 www.pcpcc.net

2 Reference: JAMA. 2009;301(6):603-618

In the Medicare Coordinated Care Demonstration project 15 orgs participated. Reimbursed varied $80 to $444 PMPM

(average of $235)2

Independence at Home Act 2009 Draft Introduction May 21; S. 1131 and H.R. 2560

• People with chronic conditions account for 76 percent of all hospital admissions, 88 percent of all prescriptions filled, and 72 percent of physician visits

• The Independence at Home Act creates a chronic care coordination pilot project to bring primary care medical services to the highest cost Medicare beneficiaries with multiple chronic conditions in their home or place of residence so that they may be as independent as possible for as long as possible in a comfortable setting

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Independence at Home Act 2009 Draft Introduction May 21

‘‘(2) INITIAL IMPLEMENTATION (PHASE I).—

‘‘(A) IN GENERAL.—In carrying out this section and to the extent possible, the Secretary shall enter into agreements with at least two unaffiliated Independence at Home organizations in each of the 13 highest cost States (based on average per capita expenditures per State under this title), in the District of Columbia, and in 13 additional States that are representative of other regions of the United States and include medically underserved rural and urban areas, to provide chronic care coordination services for a period of three years or until those agreements are terminated by the Secretary.

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Independence at Home: Sec 1312 HR 3962

Preferences

• “…have documented experience in furnishing the types of services covered by this section to eligible beneficiaries in the home or place of residence using qualified teams of health care professionals …..”

• have the capacity to provide services covered by this section to at least 200 eligible beneficiaries

• uses electronic health information systems, remote monitoring, and mobile diagnostic technology

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Independence at Home Act 2009 Draft Introduction May 21

Goals

• Improved satisfaction scores

• Improved health outcomes for patients with chronic disease

• Reduced costs:

– Hospital and skilled nursing facility admission rates and lengths of stay

– Hospital readmission rates

– Emergency department visits

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IAH Chronic Conditions(Participant Needs Two to be Eligible)

• Congestive heart failure

• Diabetes

• Chronic obstructive pulmonary disease

• Ischemic heart disease

• Peripheral arterial disease

• Stroke

• Alzheimer’s Disease and other dementias designated by the Secretary

• Pressure ulcers

• Hypertension

• Neurodegenerative diseases designated by the Secretary which result in high costs under this title, including amyotrophic lateral sclerosis (ALS), multiple sclerosis, and Parkinson’s disease

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Services and Payment Methods (Negotiated Rates with HHS)

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• Primary care services, such as physician visits, diagnosis, treatment, and preventive services

• Home health services, such as skilled nursing care and physical and occupational therapy

• Phlebotomy and ancillary laboratory and imaging services, including point of care laboratory and imaging diagnostics

• Care coordination services

Covered Services

• Per-participant, Per-month (PMPM) basis for the items and services required to be provided or made available

• Mandatory saving of at least 5% compared with traditional care

• Savings greater than 5% spilt 80/20 for initial years (“80% cent of such aggregate savings shall be paid to the organization and the remainder shall be retained by the programs under this title during the initial implementation)

Payment Method

VA Care Coordination / Home Telehealth (CCHT) • Comparisons made from one

year prior to enrollment to 6 months post enrollment in remote patient monitoring program:

• 19.74% reduction in hospital admissions

• 25.31% reduction in bed days of care Patient

• Acceptance high – only 10% declined remote monitoring

• Patient satisfaction 86%

• Average cost $1,600 per patient per annum compared to $13,121 for primary care and $77,745 for nursing home care

Reference: TELEMEDICINE and e-HEALTH. DEC 2008; VOL.14(10):1118-1126

Proof Points Re: Existing Homecare Projects • The Urban Medical Housecall program in Boston, MA has been operating for more than 30

years, currently is treating nearly 600 Medicare high cost beneficiaries with multiple chronic diseases and has reduced hospital admissions for these patients by 29% and hospital days by 34%.

• The Virginia Commonwealth Medical Center house calls program in Richmond, VA has been operating for 23 years and has reduced hospital costs by 60% for high costs beneficiaries with multiple chronic diseases.

• The Call Doctor Medical Group has operated a physician house call practice for 25 years in San Diego, CA focused on Medicare beneficiaries with multiple chronic diseases and has reduced ER visits by 59% and generated per capita savings of $1,075.

• The Home Physicians program in Chicago, IL has been operating for 15 years and currently treats 7,000 high cost Medicare beneficiaries with multiple chronic illnesses.  That program has shown a reduction in ER visits and hospitalizations from 35% to as high as 60% over the years.

• The House Call program at Montefiore Health System in the Bronx, NY has been operating for 5 years treating high cost elders with multiple chronic diseases, currently has an enrollment of 400 patients and has shown a 42% reduction in hospitalizations and a 33% reduction in total costs.

• The Mount Sinai Visiting Doctors program in New York City, NY has been operating for 14 years treating elders with multiple chronic diseases, has an annual census of 1,100 beneficiaries and has reduced hospitalizations for those patients by 66%.

• The House Call program at the Washington Hospital Center, in Washington, D.C. has been operating for 10 years, has an active census of 600 patients with 3 or more chronic diseases and has produced a 25% reduction in hospital length of stay and a 75% reduction in hospitalizations at the end of life.

• Geriatric Care of Nevada (now Geriatric Specialty Care) house call program in North Central Nevada has operated for 8 years with a patient census of 850 patients with multiple chronic diseases and has reduced hospitalizations by 27% and per patient total costs by $750.

• The GRACE house calls program in Indianapolis, IN has operated for more than 5 years and has reduced ER visits by 50% and hospitalization rates by 43% for this high cost beneficiary population.

Powers Pyles Sutter & Verville PC; 1501 M Street NW, Seventh Floor, Washington, DC 20005-1700 tel 202.466.6550, fax 202.785.1756, jim.pyles@ppsv.com | www.ppsv.com

Cost Savings Data: existing Homecare Projects Cost Savings Data: existing Homecare Projects

House Call ProgramHouse Call Program Hospital AdmissionsHospital Admissions Total CostsTotal Costs

VA Home-Base Primary Care (HBPC)VA Home-Base Primary Care (HBPC)(T. Edes, VA Data, Feb. 2009)(T. Edes, VA Data, Feb. 2009)

- 59% - 59% - 24%- 24%

Montefiore MHCP - NYCMontefiore MHCP - NYC(B. Scesney, Montefiore CMO data, April, 2009)(B. Scesney, Montefiore CMO data, April, 2009)

- 42%- 42% - 33%- 33%

U Penn House Call U Penn House Call (Naylor MD, JAMA 1999, 2004)(Naylor MD, JAMA 1999, 2004)

- 46%- 46% - $3,000 – $4,800/ patient- $3,000 – $4,800/ patient

Boston Urban Medical House Calls Boston Urban Medical House Calls (Brower E. NEJM, Dec. 2008)(Brower E. NEJM, Dec. 2008)

- 29%- 29%

ElderPACCT- Philadelphia ElderPACCT- Philadelphia (Kinosian B. JAGS (Kinosian B. JAGS 2004)2004)

- 64%- 64% - 50%- 50%

VCU- Richmond VCU- Richmond (Smigelski C. JAGS 2008)(Smigelski C. JAGS 2008)

- 60%- 60%

Hospital Readmissions(We Don’t Do a Good Job Here)

• Almost one fifth (19.6%) of the 11,855,702 Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days

• 34.0% were rehospitalized within 90 days• 50.2% of the patients who were rehospitalized within 30 days

after a medical discharge to the community, there was no bill for a visit to a physician’s office between the time of discharge and rehospitalization

• Among patients who were rehospitalized within 30 days after a surgical discharge, 70.5% were rehospitalized for a medical condition

• About 10% of rehospitalizations were likely to have been planned• The average stay of rehospitalized patients was 0.6 day longer than

that of patients in the same diagnosis-related group whose most recent hospitalization had been at least 6 months previously

• Authors estimate that the cost to Medicare of unplanned rehospitalizations in 2004 was $17.4 billion

N Engl J Med 2009;360:1418-28.

National Pilot Program on Payment Bundling

Any Medicare provider, including hospitals, physician groups, or post-acute entities interested in assuming responsibility for the bundled payment would be able to apply to participate in the pilot program. Any entity assuming responsibility for the bundled Medicare payment would be required to have an arrangement with an acute hospital for initiation of bundled services. All services provided under the bundle would be required to be provided or directed by Medicare

Participating providers. Eligible entities would receive the bundled payment for each patient served, regardless of whether patient receives certain levels of physician or post acute care.

The Secretary would be required to develop, test and evaluate alternative payment methodologies through a national, voluntary pilot program that is designed to provide incentives for providers to coordinate patient care across the continuum and to be jointly accountable for the entire episode of care starting in 2013.

If evaluations find that the pilot program achieves goals of improving patient outcomes, reducing costs and improving efficiency, then the Secretary would be required to submit an implementation plan to Congress on making the pilot a permanent part of the Medicare program.

America’s Healthy Future Act of 2009September 22 2009

National Pilot Program on Payment Bundling

CMS would calculate national and hospital-specific data on the readmission rates of Medicare participating subsection (d) hospitals and for hospitals paid under section 1814 (b)(3) for eight conditions that the Secretary selects based on spending and readmission rates.

Starting in FY 2012, the Secretary would share these data with hospitals, and the data would be publicly reported on the Hospital Compare website.

Starting in FY 2013, hospitals with readmission rates above a certain threshold would have payments for the original hospitalization reduced by 20 percent if a patient with a selected condition is re-hospitalized with a preventable readmission within seven days and by ten percent if a patient with a selected condition is re-hospitalized with a preventable readmission within 15 days.

America’s Healthy Future Act of 2009September 22 2009

Chairman‘s Mark would require the Secretary to create an Innovation Center within the Centers for Medicaid and Medicare Services (CMS)

The Chairman‘s Mark would appropriate $10 billion from the Part A and Part B Trust Funds to the Center over 10 years

The Innovation Center will be a new office established within CMS that is authorized to test, evaluate, and expand different payment structures and methodologies which aim to foster patient-centered care, improve quality, and slow the rate of Medicare cost growth.

The Center would be required to conduct an evaluation of each model tested, including an analysis of the extent to which the model results in:

1. coordination of health care services across treatment settings

2. reduction of preventable hospitalizations;

3. prevention of hospital readmissions;

4. reduction of emergency room visits;

5. improvement in quality and health outcomes

6. improvement in the efficiency of care

7. reduction in the cost of health care services covered under this title

8. achievement of beneficiary and family-caregiver satisfaction.

America’s Healthy Future Act of 2009September 22 2009

The Innovation Center

Promote broad payment and practice reform in primary care, including patient-centered medical home models for high-need beneficiaries, medical homes that address women‘s unique health care needs, and models that transition primary care practices away from fee-for-service based reimbursement and toward comprehensive payment;

2. Contract directly with groups of providers and suppliers to promote innovative care delivery models, such as through risk-based comprehensive payments

3. Support care coordination for chronically-ill Medicare beneficiaries at high risk of hospitalization through a health IT-enabled network that includes a chronic disease registry, home tele-health technology, and care oversight by the beneficiary‘s treating physician;

America’s Healthy Future Act of 2009September 22 2009

In selecting models for testing, the Secretary shall also consider

1. Foster care coordination for high-cost, chronically ill Medicare beneficiaries who are at highest risk for hospitalization or readmission;

2. Place the patient, including family members and other informal caregivers, at the center of the care team;

3. Include, but are not limited to, in-person contact with beneficiaries;

4. Utilize technology, such as electronic health records and patient-based remote monitoring systems, to coordinate care over time;

5. Maintain a close relationship between care coordinators and primary care practitioners;

6. Rely on a team-based approach to interventions such as comprehensive care assessments, care planning, and self-management coaching.

America’s Healthy Future Act of 2009September 22 2009

Accountable Care Organizations (ACOs)

CMS would assign Medicare fee-for-service beneficiaries to ACOs based on their use of Medicare items and services in preceding periods

ACOs with three-year average Medicare expenditures that are determined by CMS to be below their benchmark for the corresponding period would be eligible for shared savings at a rate determined appropriate by the Secretary. The Secretary would be required to set a minimum threshold of savings that would need to be achieved by an ACO before savings would be shared

America’s Healthy Future Act of 2009September 22 2009

To qualify as an ACO, an organization would have to meet at least the following criteria:

(1) agree to become accountable for the overall care of their Medicare fee-for-service beneficiaries;

(2) agree to a minimum three-year participation; (3) have a formal legal structure that would allow the organization to

receive and distribute bonuses to participating providers; (4) include the primary care physicians for at least 5,000 Medicare fee-for-

service beneficiaries; (5) provide CMS with information regarding primary care and specialist

physicians participating in the ACO as the Secretary deems appropriate; (6) have arrangements in place with a core group of specialist physicians; (7) have in place a leadership and management structure, including with regard

to clinical and administrative systems; (8) define processes to promote evidence-based medicine, report on quality and

costs measure, and coordinate care; and (9) demonstrate to the Secretary that it meets patient-centeredness criteria

determined by the Secretary, such as use of patient and caregiver assessments or the use of individualized care plans.

America’s Healthy Future Act of 2009September 22 2009

What is Care Coordination?

• Team work? Family Health Teams (FHTs)?• Improved communications between care deliver

sites? – crucial points for breakdown being admission to and

discharge from hospitals into homecare environment and visa versa

– Communication across the continuum of care

• Care summaries generated with every visit /discharge

• Improved health status/outcomes?• Patient empowerment? PHRs?

– On line patient coaching– Self care management tools

• Improved care giver efficiency?

Putting it All Together: New Business Models That We Can Start With NOW

At Risk Patient Populations

• Home Healthcare Agencies started it all: PPS

• Medicare Advantage• Medicaid HMOs• At risk contracts with

Federal, State, County orgs• Uninsured

Caring For Populations With Less

Costly Infrastructure

Consumer Out Pocket Models

What might a business model look like?

Would insurance pay?

Would consumers pay out of pocket?

Would employers pay?

BACK UP

J Card Fail. 2008 Mar;14(2):121-6.Managing heart failure care using an internet-based telemedicine system.Kashem A, Droogan MT, Santamore WP, Wald JW, Bove AA.Section of Cardiology, Temple University School of Medicine, Philadelphia, Pennsylvania 19140, USA.BACKGROUND: Managing patients with heart failure (HF) is labor intensive, and follow-up is often inadequate to detect day-to-day changes that ultimately lead

to decompensation. We tested the effect of an Internet-based telemedicine (T) system that provides frequent surveillance and increased communicate between HF patients and their provider on frequency of hospitalization in a cohort of patients with advanced HF. METHODS AND RESULTS: HF patients in NYHA Class II-IV were randomized to usual care (UC, n = 24) or T (T plus UC, n = 24) and followed for 1 year. Office visits, emergency department visits, hospitalizations, telephone calls, and number of Internet communications were measured over the 1-year period. Left ventricular ejection fraction (EF) was assessed by echocardiography in both groups. For T, mean age was 53.2 +/- 2.0 years (72% male, 61% Caucasian, 39% African American). For UC, mean age was 54.1 +/- 2.6 years (76% male, 72% Caucasian, 14% African American, and 14% Hispanic). HF etiologies and EF were similar in both groups. During the 12-month period, UC had 74 total phone calls to the practice, whereas T had 88 telephone calls plus 1887 telemedicine data messages (6.5 messages/patient/month). ER visits were lower in the T group (T 5, UC 12; P < .05). Hospital admissions (T 24, C 40; P = .025) and total hospital days (T 84, UC 226 days; P < .005) were lower in T. Unscheduled clinic visits (T 13, UC 13; P = NS) and scheduled clinic visits (T 78, UC 94; P = NS) were similar in both groups. CONCLUSIONS: Frequent monitoring and patient management using a telemedicine system may help to reduce hospitalizations, hospital days, and emergency department visits

Telemed J E Health. 2008 Sep;14(7):679-86.Cost comparison between telemonitoring and usual care of heart failure: a systematic review.Seto E.Centre for Global eHealth Innovation, University Health Network, Toronto, Ontario, Canada. emily.seto@uhn.on.caHeart failure (HF) is associated with high direct and indirect costs to the patients and the healthcare system. This systematic review aims to analyze existing

economic data to determine whether telemonitoring of patients with HF will result in decreased costs. The Scopus and PubMed databases were searched independently by two reviewers for journal articles that reported on an economic analysis (i.e., calculated monetary amounts or percentage change in costs) of a study using a HF telemonitoring system. Only articles describing telemonitoring systems with a component of home physiological measurements were included. Eleven articles met the inclusion criteria, describing 10 different HF telemonitoring systems. Nine of the 10 studies analyzed the direct costs to the healthcare system. All the studies found cost reductions from telemonitoring compared to usual care, which ranged between 1.6% and 68.3%. Cost reductions were mainly attributed to reduced hospitalization expenditures. Only one study discussed the impact of HF telemonitoring on direct patient costs. The study found a 3.5% lower travel cost for patients using telemonitoring compared to those in the usual care group. The single study that was found for indirect costs described the willingness to pay for telemedicine by patients with HF (55% of the patients with HF were willing to pay $20 to access telemedicine, and 19% were willing to pay $40). Available data from existing studies suggest that although HF telemonitoring will require an initial financial investment, it will substantially reduce costs in the long term, particularly by reducing rehospitalization and travel costs

J Card Fail. 2007 Feb;13(1):56-62.Telemonitoring for patients with chronic heart failure: a systematic review.Chaudhry SI, Phillips CO, Stewart SS, Riegel B, Mattera JA, Jerant AF, Krumholz HM.Department of Internal Medicine, Section of General Medicine, Yale University School of Medicine, New Haven, Connecticut 06520-8025, USA.BACKGROUND: Telemonitoring, the use of communication technology to remotely monitor health status, is an appealing strategy for

improving disease management. METHODS AND RESULTS: We searched Medline databases, bibliographies, and spoke with experts to review the evidence on telemonitoring in heart failure patients. Interventions included: telephone-based symptom monitoring (n = 5), automated monitoring of signs and symptoms (n = 1), and automated physiologic monitoring (n = 1). Two studies directly compared effectiveness of 2 or more forms of telemonitoring. Study quality and intervention type varied considerably. Six studies suggested reduction in all-cause and heart failure hospitalizations (14% to 55% and 29% to 43%, respectively) or mortality (40% to 56%) with telemonitoring. Of the 3 negative studies, 2 enrolled low-risk patients and patients with access to high quality care, whereas 1 enrolled a very high-risk Hispanic population. Studies comparing forms of telemonitoring demonstrated similar effectiveness. However, intervention costs were higher with more complex programs (8383 dollars per patient per year) versus less complex programs (1695 dollars per patient per year). CONCLUSION: The evidence base for telemonitoring in heart failure is currently quite limited. Based on the available data, telemonitoring may be an effective strategy for disease management in high-risk heart failure patients.