it solutions for fee for value reimbursment and population health management

TECHNOLOGY CONSIDERATIONS FOR VALUE-BASED PAYMENTS

John SqueoLazer Focus AdvisorsFind us on LinkedIn

1% of U.S. population consumes20% of ALL HEALTH CARE DOLLARS

Source: National Institute of Health Care Management 2012

CHALLENGES WE FACE

1% of U.S. population consumes20% of ALL HEALTH CARE DOLLARS


Total expenditure on healthcare:per capita per year: $7,960

Source: Organization for Economic Co-operation and Development on global health issues: Michael B. Sauter, Charles B. Stockdale, 24/7 Wall St. , 2012 - Countries that spend the most on health care, NBCNEWS.com, http://www.nbcnews.com/business/countries-spend-most-health-care-618241

Expenditure as percent of GDP: 17.4 percent

CHALLENGES WE FACE

HEALTHCARE REFORM

#1 Biggest Issue – Financial Challenges

#2 Biggest Issue – Healthcare Reform Implementation

#3 Biggest Issue – Patient Safety & Quality

2011 Results - Biggest Issue Facing Hospital CEOs

Source: American College of Healthcare Executives, Annual Poll – Top Issues Confronting Hospitals: 2012

Annual Survey American College of Healthcare Executives

HEALTHCARE REFORM

#1 Biggest Issue – Financial Challenges

#3 Biggest Issue – Healthcare Reform Implementation

#2 Biggest Issue – Patient Safety & Quality

2012 Results - Biggest Issue Facing Hospital CEOs

Source: American College of Healthcare Executives, Annual Poll – Top Issues Confronting Hospitals: 2012

Annual Survey American College of Healthcare Executives

TRENDS TOWARD VALUE-DRIVEN HEALTHCARE

• Hospital Readmissions– Hospital DRGs 1% in 2013 3% by 2015• Medicaid DSH cuts - $18.1Billion 2014 – 2020 (Pres. Obama

proposed delay to 2015)• Value-Based Purchasing• 70% - Core Measures: Heart Failure, Acute Myocardial Infarction

(AMI), Pneumonia & Surgical Care• 30% - HCAHPS score: Patient Satisfaction

• Physician (SGR) Sustainable Growth Rate – 27%

Reduced Reimbursements CMS & Commercial Carriers

• Accountable Care – Provider Risk Acceptance & Shared Savings• Bundled payment for episodic care

Global Payments Innovations – CMS & Carriers

• Payers setting up Accountable Care Organizations• Hospital Systems offering health insurance on public Health Insurance

Exchanges (HIX)

Payer/Provider Convergence

HHS & IL HFS INNOVATION MODELS

HHS & ONC BEACON COMMUNITIESHIE - HEALTH INFORMATION EXCHANGES

SEMANTICAL INTEROPERABILITY

MASTER PROVIDER INDEXES MASTER PATIENT INDEXES CONSENT MANAGEMENT &

RECONCILIATION

ILLINOIS - Care Coordination Programs CCE - Seniors and Persons with Disabilities CCMN - Children with Complex Health Needs MMAI - Medicare-Medicaid Alignment Initiative ICP - Integrated Care Project and Integrated

Care Expansion

ACO – ACCOUNTABLE CARE ORGANIZATIONS

BUNDLED PAYMENTS FOR CARE IMPROVEMENT

PRIMARY CARE TRANSFORMATION

MEDICAID & CHIP POPULATION INITIATIVES

DUAL ELIGIBLES INITIATIVES

PAYMENT & SERVICES DELIVERY MODEL ACCELERATION

BEST PRACTICE ADOPTION INITIATIVES

CMMI INNOVATION MODELS

ACCOUNTABLE CARE SIMPLIFIED

Year 1 Attributi

on

Year 2

Year3 Shared Savings

ACOCMS or Other

PayerACO


Year 1 Attributi

on

Year 2


ACOCMS or Other

Payer

Risk Score

Profiling

Chronic Disease

Monitoring

ACO


Year 1 Attributi

on

Year 2


ACOCMS or Other

Payer

Risk Score

Profiling

Chronic Disease

Monitoring

Care Coordination

Pre & Post Acute Care

ACO

THE OPPORTUNITY

Managed Care and Value-Based Care has provided us the privilege and responsibility to

Never Discharge a Patient.

We can dedicate our efforts to help them grow, contribute and then age with dignity.

TRANSFORMATIONS IN HEALTHCARE DELIVERY


MOVEMENT AWAY FROM CENTRALIZED FACTORIES OF

CAREHospital



CAREHospital

CONSUMER DRIVEN HEALTH CARE

Source: http://www.nytimes.com/interactive/2013/05/08/business/how-much-hospitals-charge.html

COMPACT RADIUS OF PATIENTS/COMMUNITY DEFINED PAYER MIX


HOSPITAL PATIENT CAPTURECURRENT STATE


CAREHospital




SILVER TSUNAMI – Seniors Aging In Their Homes

78 Million Baby Boomers turned 65 in 2011 9 out of 10 seniors want to stay in the home they

retied in

Source: AARP survey

REDUCED HOSPITAL READMISSIONSREDUCED HOSPITAL (LOS) LENGTH OF

STAY

+

__________________________________________


CAREHospital




SILVER TSUNAMI – Seniors Aging In Their Homes

78 Million Baby Boomers turned 65 in 2011 9 out of 10 seniors want to stay in the home they

retied in

Source: AARP survey

REDUCED HOSPITAL READMISSIONSREDUCED HOSPITAL (LOS) LENGTH OF

STAY

+

__________________________________________

EXPANDED RADIUS OF PATIENTSEXPANDED PAYER MIXBIG DRIVE TIME TO REACH PATIENTS


CAREHospital



PATIENT ACTIVATION TRIGGERS

Driving change…from a distance

Source: Southcentral Foundation, “The Trust for Health Excellence’s Better Health Initiative”

PATIENT ACTIVATION TRIGGERS

Driving change…from a distance


Influence the RIGHT PEOPLEat theRIGHT TIMEat theRIGHT PLACEby theRIGHT METHOD

USE PATIENT OUTREACH TO

R4

SHIFTING FOCUSPRE & POST ACUTE AND HOME SETTINGS

REDESIGNING PRIMARY CARE


PATIENT-CENTERED MEDICAL HOMES

Looking “in” on the patient Looking “out” to the Health Care Environment

PATIENT-CENTERED MEDICAL HOMES

Looking “in” on the patient Looking “out” to the Health Care Environment

Patient-centered medical homes (PCMH) – Not necessarily a “place” rather a central point from which assistance is provided to navigate the fragmented healthcare system Source: Oliver Wyman, Tom Main & Adrian Slywotzky

PATIENT PORTAL E-CONSULTS

HEALTH PLAN CO-PAYs All Metallic plans on Public Health Insurance Marketplace & SHOP Exchanges

DIRECT PAYMENT FOR E–CONSULTS RANGE - $50 - $100

NO CLAIMS ADJUDICATION NECESSARY

CONVENIENCE OF ACCESS DRIVES PATIENT ENGAGEMENT

STEERS ADOPTION OF ELECTRONIC PATIENT PORTAL USAGE

1990s MANAGED CARE ALL OVER AGAIN?OR DIFFERENT THIS TIME?

PAY FOR PERFORMANCE


PAY FOR PERFORMANCE

EHRs Capture the discrete data electronically


Clinical Integration within IDNsClinical Registry Data – Reviewed by Physicians providing the

careICD-9/10 & HCPCS from PMS and CPT/DRG Diagnosis from EHR

PAY FOR PERFORMANCE



Clinical Integration within IDNsClinical Registry Data – Reviewed by Physicians providing the

careICD-9/10 & HCPCS from PMS and CPT/DRG Diagnosis from EHR

Payer incentives to providersPQRS, Tiered Narrow Networks, Core Measures, ACOs

PAY FOR PERFORMANCE


CLINICAL METRIC REGISTRIES

The year 2048

333333

SOME UNNERVING STATS

100% of Americans could be overweight or obeseSource: AHRQ US Government Agency for Healthcare Research and

Quality

The year 2048

333333


100% of Americans could be overweight or obeseSource: AHRQ US Government Agency for Healthcare Research and

Quality

The year 2048

% of patients take All their meds% of patients take Some of their meds% of patients take None of their prescribed meds Costing Americans $46 Billion in avoidable acute facility admissions

Source: NY Times referencing Standberg, L.R., Drugs as a Reason for

Nursing Home Admissions, American Health Care Journal

333333


Financial Savings Potential from Medication Adherence

Chronic Condition Savings Per Patient per Year

Congestive Heart Failure – CHF

$7,823

Hypertension $3,908

Diabetes $3,756

High cholesterol $1,258Source: CVS Caremark Research Partnership: Advancing Adherence & the Science of Pharmacy Care, Volume 2. Page 5www.cvscaremarkfyi.com/sites/all/themes/cvs_theme/11-CVS-346-NPC_2012_compendium_final_web.pdf

IF WE JUST TOOK OUR MEDICINETHE MONEY WE COULD SAVE

Financial Savings Potential from Medication Adherence

Chronic Condition Savings Per Patient per Year

Congestive Heart Failure – CHF

$7,823

Hypertension $3,908

Diabetes $3,756

High cholesterol $1,258Source: CVS Caremark Research Partnership: Advancing Adherence & the Science of Pharmacy Care, Volume 2. Page 5www.cvscaremarkfyi.com/sites/all/themes/cvs_theme/11-CVS-346-NPC_2012_compendium_final_web.pdf

IF WE JUST TOOK OUR MEDICINETHE MONEY WE COULD SAVE

We need to leverage New Methods to PROMOTE HEALTHY HABITS!

BASICS OF HABITS

“As the rats were learning, the reinforcement signal goes away, because you really don’t need it”

Source: Dr. Ann Graybiel, MIT: Brain rhythms arekey to learning New study from MIT neuroscientists finds that brain waves shift frequency as a new task becomes routine.Anne Trafton, MIT News Office, November 27, 2011

BASICS OF HABITS

HABITS TAKE THE PLACE OF CONSCIENCE DECISION


Back out of Driveway


Drive to WorkBack out of Driveway


Drive to WorkBack out of Driveway Get to the Office

Realize you CAN’T REMEMBER the actual trip itself. As if in a Trance



Process of Emotional Eating Can be a similar experience

Realize you CAN’T REMEMBER the actual trip itself. As if in a Trance



Cues Routines Rewards

HABITS BECOME HARD WIRED

Cues Routines Rewards

HABITS BECOME HARD WIRED

AUTOPILOT

NEED FOR DECISIONINFLUENCE AND

COACHING

You better cut the pizza in four pieces because I’m not hungry enough to eat six.

~ Yogi Berra

NEED FOR DECISIONINFLUENCE AND

COACHING

$90,000

$41,000

$236

COST BREAK DOWNAverage Annual Healthcare

Spend in USAPer Person

1% OF INSURED

50% O

F

INSURED

5% OF INSURED

Heart Disease

Diabetes

Arthritis

Asthma


WHAT CAN THE DATA TELL US?

COST

DRIVERS

GET THE DATA SET - SOURCES

Access to Discrete (Patient Identified) Claims Data of population1. ASO (Self-Funded Plan) or ACO (Entitlement or Commercial)2. HIE from Practice Management Systems or Patient Billing Systems




Clinical Data – HIE from EHR or Clinical Integration Registry


Medication Data1. Claims from ASO (Self-Funded Plan) or ACO (Entitlement or

Commercial)2. HIE from E-Prescribe system, E-Prescribe transaction hub

(Surescripts) or directly from the PBM (if permitted by plan design and regulations)


Clinical Data – HIE from EHR or Clinical Integration Registry

AGGREGATE - MAP & ANALYZE DATA


OLAP/SQL


RISK SCORESEpisode Risk Groups (ERGs)Episode Treatment Groups (ETGs)Hierarchical Condition Categories (HCC)

OLAP/SQL

Advanced Predictive Model Determines “Risk Index” and Care Method

Risk/Cost Profile: Total Population

Costs

n =

Pop

ulat

ion

Size

Adju

sted

Risk

Inde

x

RISK STRATIFIED POPULATION


Clinicians (PCP and Mid-Level)• Targeted at very top ranked

members who benefit from intensive intervention model by MD team


Costs

n =

Pop

ulat

ion

Size

Adju

sted

Risk

Inde

x





Nurse Coach• Team-based model targeted at

high-opportunity members


Costs

n =

Pop

ulat

ion

Size

Adju

sted

Risk

Inde

x





Core Chronic Disease Management• Program delivering disease-customized

content for disease-identified members• Standards of care and HEDIS




Costs

n =

Pop

ulat

ion

Size

Adju

sted

Risk

Inde

x







Lifestyle Coach• Members prioritized by Risk Profile severity• Coaching based on modifying lifestyle risks

that lead to increasing medical costs




Costs

n =

Pop

ulat

ion

Size

Adju

sted

Risk

Inde

x












Self-Management (Web and Multi-Modal)• Customized via members’ participation in

the WBA, a Well-Being Plan organizes web content to serve the individual needs of the member self-managing healthy behavior improvement

Costs

n =

Pop

ulat

ion

Size

Adju

sted

Risk

Inde

x









Surveillance• Some members may not participate in the

WBA• Via routine Claims Analysis and Predictive

Model runs, 100% of the population is continuously evaluated & re-prioritized for program intervention






Costs

n =

Pop

ulat

ion

Size

Adju

sted

Risk

Inde

x









Surveillance• Some members may not participate in the

WBA• Via routine Claims Analysis and Predictive

Model runs, 100% of the population is continuously evaluated & re-prioritized for program intervention






Costs

n =

Pop

ulat

ion

Size

Adju

sted

Risk

Inde

x

Readmission Avoidance Program• Event-based rather than cohort-based• The Discharge event and the member’s relative

risk index are considered in evaluating the need for an outreach call

• Members’ transition from Hospital to aftercare are coordinated to reduce readmission likelihood


POPULATION HEALTH MANAGEMENT SOLUTIONS

TECHNOLOGY IS GREAT….BUT ALL THAT MATTERS IS THE

OUTCOME

Source: Marc Prensky - Digital Natives, Digital Immigrants published in 2001

Digital Natives born after 1996Digital Immigrants born prior to 1996

Digital NomadsMobile Bohemian – Mobos

Senior Living

Community Health Advisor

Family Advocate

Health Educator

Health Liaison

Health Promoter

Outreach Worker

Peer Counselor

Patient Navigator

Health Interpreter

Public Health Aide

Social Worker

Manicurist

Hair Stylist

Gym Instructor

Personal Trainer

Meals on Wheels

Senior Centers

Support Groups

Respite Care

Integrative Medicine

AcupunctureHealing Touch

Massage TherapyGuided Imagery

Clergy

Home Health Care

Case ManagerHospital

Primary Care Giver

Rehab

LTACSNFsHospice/Palliative

Care

Nurse Navigator Pharmacis

t

Vitamin/Herb

Retailers

Cessation programs

TobaccoAlcoholDrugs

Behavioral Programs

Probation Officers

Anger Managers/Coaches

Chiropractor

OT/PT/ST

PCP/NP/PA/PCMH

Psychologist

Psychiatrist

Medical Specialists

Hospitals

Hospitalists

DME Providers

Intensivists

Dietician

Wound Care

Case Manager

Payer/ACO

Diet Coach

Medical Transport

Transitional Care Nurse

PATIENT INFLUENCE CONTINUUM

Source: Microsoft

Cosmetic surgeon

CARE TEAM COLLABORATION SOFTWARE CONSIDERATIONS


Case & Disease Management – Workflow Mngt & Assessments Longitudinal Care Plans & Plan Adherence



Contact Information Directory



Open Access platform for multitude of Caregivers




Open Access platform for multitude of Caregivers Appointment Scheduling and Coordination




Open Access platform for multitude of Caregivers Appointment Scheduling and Coordination Escalation for unacknowledged messages or results




Open Access platform for multitude of Caregivers Appointment Scheduling and Coordination Escalation for unacknowledged messages or results Nimble architecture – SOA based on Web Services




Open Access platform for multitude of Caregivers Appointment Scheduling and Coordination Escalation for unacknowledged messages or results Nimble architecture – SOA based on Web Services Middleware adapter and business logic for outreach via text or IVR.




Open Access platform for multitude of Caregivers Appointment Scheduling and Coordination Escalation for unacknowledged messages or results Nimble architecture – SOA based on Web Services Middleware adapter and business logic for outreach via text or IVR.


HIE protocol capabilities – HL7, SNOMED, LOINC

CARE TEAM COLLABORATION

SOFTWARE

Web Email Text/

MobileMail

Social Communities IVRTelephonic Face-to-

FaceHome Care

REACH THE TARGET -

THE PREFERRED WAY

COACH THE PATIENT

Web Email Text/

MobileMail

Social Communities IVRTelephonic Face-to-

FaceHome Care

REACH THE TARGET -

THE PREFERRED WAY

COACH THE PATIENT

Fall Risk

CREATE PROVIDE TEACHA SINGLE POINT OF HEALTH NAVIGATION

Source: Oliver Wyman, The Volume-To-Value Revolution, Rebuilding the DNA of Health from the Patient in, Tom Main & Adrian Slywotzky, 2012

TELEMEDICINE FOR “Wired Homes”

Qualcomm Life 2net

Sensors


Qualcomm Life 2net

Sensors

Implantable

In Vivo Glucose Monitor


Qualcomm Life 2net

Sensors

Implantable


Wearable

fitbit


Qualcomm Life 2net

Sensors

Implantable


Wearable

fitbit

Behavior Tracking

Glowcaps

mHealth

mHealthIn Apple App Store18,564 Medical Apps22,817 Healthcare & Fitness Apps

Source: http://148apps.biz/app-store-metrics, May 1, 2013

mHealth

www.monitoringcare.com

TeleHealth

Integrators

In Apple App Store18,564 Medical Apps22,817 Healthcare & Fitness Apps


mHealth


TeleHealth

Integrators



Telemedicine Solutions

mHealth


TeleHealth

Integrators

Data Aggregators- MDI




mHealth

Case Studies


TeleHealth

Integrators





mHealth

Case Studies


TeleHealth

Integrators





Trade Shows

Incent Personal Accountability

Source: Healthways

Use Holistic Analysis to isolate ROOT of Unhealthy Habits

BEHAVIOR ECONOMICS

Recruit Individual into Social Support Networks to foster positive peer awareness

Realign the FINANCIAL RI$K shared among Employers, Payers and Employees toward a common set of achievable goals

BEHAVIOR ECONOMICS

CARROTS

Commitment Contract - $$ gain for meeting period goals, $$ at risk for not meeting goals

Daily Challenges – Organized daily or weekly challenges

among work peers (Biggest Loser), Pedometer competitions

STICKS

$500-$1000/yr Surcharge for non-participation in Biometric Screening

Tobacco usage – ranging around $2000/yr surcharge to Non-Hiring policies of tobacco users

TACTICS FOR HEALTHY BEHAVIORS

HABIT CHANGING TOOLS TO WATCH

ACHIEVABLE MISSIONS

1969 1979 1989 1999 2009 2019 2029 2039 2049

ALL COACHING IS:

IS TAKING A PLAYER WHERE HE CAN’T TAKE HIMSELF

~ Bill McCartneyCollege Football Coach

COACHING HEALTH FOR WINNING OUTCOMESIN A PAY-FOR-VALUE ECONOMY

Reach me atLinkedIn: John Squeo

TECHNOLOGY CONSIDERATIONS FOR VALUE-BASED PAYMENTS

it solutions for fee for value reimbursment and population health management

Health & Medicine