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Population Health ManagementIN A FEE-FOR-SERVICE WORLDTracy Mitchell, MSHS, RN, CPHQSystem Administrative Director, Population Health

CoxHealth

Learning Objectives

� Describe risk stratification tactics used in population health management

� Describe utilization management methods and considerations for selecting appropriate post-acute care site of service

� Explain the importance of engaging patients and families in advance care planning activities

� Understand drivers and barriers to value-based care

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Population Health Defined?

� Population health is defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group. ~D. Kindig, & G. Stoddart 2003

� Population health management - managing and paying for health care services for a discrete / defined population.

� It is the design, delivery, coordination, and payment of high quality health care services to manage the Triple Aim for a population.

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Why Population Health?

� DHHS / CMS moving toward value-based paymentsystems

� Commercial payers are following suit

� Aging population, multiple chronic conditions

� Unsustainable trend in health care spend

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Population Health by the Numbers

� 10,000 Baby Boomers turning 65 every day

� By 2030, 18% of U.S. population will be at least 65 years old

Source: U.S. Census Bureau

Source: CDC.gov. https://www.cdc.gov/chronicdisease/about/index.htm

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Status Quo - Unsustainable

Ssource: CBO 2018 Budget and Economic Outlook (April 2018): https://www.cbo.gov/system/files/115th-congress-2017-2018/reports/53651-outlook.pdf

And a Looming Medicare Cost Crisis

o 10,000 aging into Medicare each day

o Rapid growth in Trust Fund expenditures projected: 7% over next decade, including ~10% annual growth from 2019-2022

o Trust Fund estimated to be insolvent by 2026

$200

$250

$300

$350

$400

$450

$500

$550

$600

$650

2016 2018 2020 2022 2024 2026 2028

Trust Fund Balance

Medicare Expenditure

Billi

ons

Rising Federal Deficits Fueled by

Health Spending

Source: CBO 2018 Budget and Economic Outlook (June 2018): https://www.cbo.gov/system/files?file=2018-06/53919-2018ltbo.pdf

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Our Approach: Data-Driven Initiatives

Collaborate and integrate care to drive clinical outcomes

Aggregate data & track actual vs. planned costs

to focus on outcomes

Flag patients to ensure care coordination and participation in care

Use outcome and cost data

to select plan design/risk contracts

Identify & Engage

Plan &Manage

Mine &Analyze

Select & Prioritize

Identify and target savings initiatives using available data sources

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Care Management Programs

Transitions Care

Complex Care

Advanced Illness Care

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“Whether you are a patient, a provider, a business, a health plan, or a taxpayer, it is in our common interest to build a health care

system that delivers better care, spends health care dollars more wisely and results in

healthier people.”

~HHS Secretary Sylvia Burwell January 26, 2015

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“There is no turning back to an unsustainable system that

pays for procedures rather than value. The only option is to

charge forward…to take bolder action”

- Alex Azar, March 5, 2018

“If [payment] needs to be mandatory as opposed to voluntary to get adequate

data, then so be it.“- Alex Azar, January 9, 2018

“I’d like to banish fee-for-service ,”… I don't necessarily

mean capitating everybody ... [but] fee-for-service means paying just

on the basis of what you do, rather than quality or outcomes.”

- Adam Boehler, August 30, 2018

HHS/CMS is committed to more

aggressive risk programs and

concerned about hospitals “squatting”

in one-sided risk“Majority of ACOs have yet to move to any downside risk. Our

system cannot afford to continue with models that are

not producing results ”- Seema Verma, May 7, 2018

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201620162016201630%

In 2016, at least 30% of

U.S. health care payments

are linked to quality and

value through APMs

201820182018201850%

In 2018, at least 50% of

U.S. health care

payments are so linked.

Better Care, Smarter Spending, Healthier People

Yesterday’s News… 11

Continuum of Medicare Risk Models

Source: Health Care Advisory Board interviews and analysis 2018.

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Healthcare’s Value Transformation 13

Value-Based Care Transformation

As Care moves from TRANSACTIONAL to RELATIONAL ; Workflows shift from EPISODIC to CONTINUAL ;

COMPENSATION ALIGNS with VBC operating model behaviors

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Key Drivers

� Infrastructure to support successful implementation

� Develop robust IT architecture to support episode of care

� Care coordination throughout episode & across care settings

� Physician involvement in care redesign

� Collaboration on best practices, expectations

� Generate and use actionable data across the clinical episode

� Improve processes & redesign care

� Patient engagement

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VBC Operating Model

�Value-Based Practice Operating Model

� Risk adjusted panel – on the horizon (maturity)

� Care is relational with fluid communication

� VBC Tools & PHM reporting

�Align Providers through CompensationReform

� Risk-adjusted panel size – on the horizon (maturity)

� Quality� Efficiency� PHM

�Any Access / Scalable Care

� Text, email, phone, telehealth, portal� Behavioral healthcare is healthcare� Connect providers, patients, care team,

community resources, etc. on one platform � Integrate other source data, including SDoH� Telehealth becomes and access point /

medium of care

Improve Clinician

Experience

Improve Patient

Experience

Impr

ove P

opula

tion

Health

Reduce

Cost

s

Source: IHI.org

http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx

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Delivering Clinical Value Requires a Two-Pronged Approach

CLI

NIC

AL

VALU

E D

ELI

VE

RE

D

Holistic Transformation to Value-Based Care Care Management and Coordination

Provider-Led Care Delivery and Practice Patterns

Drives rapid value by impacting ambulatory care-sensitive inpatient admissions, avoidable readmissions and end-of-life care not in-line with patient goals

Broader provider-led transformation efforts that leverage programs, resources and analytics to support complex patient cohorts, reduce use of lower-value services and integrate value-based care goals into every day decision making

Source: Evolent Health

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Value-Based Delivery Operating Model: 5 C’s of Change

Care Connect Communicate Capitate Compensate

Predictive Analytics & Patient

IdentificationSingle platform

Care team and patients on same

communications platform

Support Delegated Services & CDQI

Optimization

Aligned Compensation Modeling &

Administration

Wrap-around Services; VBS and MCOE programs

Smart-integrations Any Access Downstream payments

Specialty Networks and Incentives

Quality, Wellness and Prevention

Seamless continuum and program goals

Health Literacy Enablement,

Hybrid MSO Services

Governance, Shared Savings, and Funds

Flow

Workflow Ops Models

Community Resources & FQHC

networks

Alerts/Reminders forProviders, Team, &

Patients; campaigns

Capital Partner orHealth Plan;

Network Management

Engagement throughFull-Panel Reporting

Source: Evolent Health

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Opportunities in Care Transformation

Primary Care

� PCPs as advocates of clinical programs

� Practice workflow optimization

� Panel monitoring & patient friendly scheduling

� Reduce unwarranted variation in referral patterns

� Integrating value-based care goals into comp models

Hospitals

� Integrating into discharge planning

� Collaboration on patient engagement

Specialists

� Evidence-based care pathway integration

� Shared decision making for preference-sensitive procedures

� Pre-surgical optimization

� Site of Service shifting

� Low-value services and Choosing Wisely

� Engaging specialty providers

Post-Acute Care

� Address deficiencies in quality

� Providing more consistent clinical care

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Common Diagnosis Codes 20

Capturing Burden of IllnessTypical Documentation Greater Specificity

70 year old

patient

Dx HCC RAF

Value

DM, type 2

(no chronic

complications)

E11.9 19 .104

Peripheral

Vascular disease

I73.9 108 .298

Congestive Heart

Failure, not coded

No Interaction

Total RAF Score.402

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Documenting that these diseases are due to each other or because of

each other is what indicates a more complex chronic condition the

provider is managing. This results in a higher HCC category.

70 year old

patient

Dx HCC RAF

Value

DM, type 2

w/circulatory

complications

E11.59 18 .307

Varicose veins,

lower RT

extremity, ulcer

I83.019 107 .400

Congestive Heart

Failure

I50.9 85 .323

Disease

interaction DM +

CHF

.152

Total RAF Score1.182

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The Case for Cardiac Rehab

Source: Hammill BG, Curtis LH, Schulman KA, Whellan DJ. Relationship between cardiac rehabilitation and long-term risks of mortality and myocardial infarction among elderly Medicare beneficiaries. Circulation. 2010; 121:63–70.

Cumulative incidence of mortality by number of cardiac rehab sessions

attended

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Site of Care

‘Spending on care after surgery is driven by choice of care settingsinstead of intensity of services’ – Health Affairs, 2017

‘For surgical discharges, whether patients received IP Rehab was the key driver of variation in PAC spending; for medical discharges, whether patients received SNF care was the key driver.’ – Health Services Research, 2016

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Post-Acute Care

� The average cost of a skilled nursing facility stay is $11,357 versus just $2,720 for a home health care episode

Source: CMS.govhttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/Downloads/IMPACT-Act-MSPB-MLN-Connects-Call-September-2017.pdf

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Preferred SNFs

� CoxHealth providers at selected facilities

� Clinical program capability

� Respiratory therapy

� Wound care

� Ability to treat complex pts

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PAC Collaboration

� Foster collaboration between CoxHealth, SNFs / HHC and physician

practices

� Establish joint clinical protocols and quality measures for patients

transitioning from settings

� Improve clinical integration and knowledge transfer

� Reduce the frequency of avoidable emergency visits and hospital

readmissions

� Improve post-acute clinical capacity and practice

� Reduce overall spending while ensuring access to care and choice

of provider

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Advance Care Planning

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Quality of Life?

� 42% of patients died at home: $4,760

� 40% of patients died in the hospital: $32,379

� 7% of patients died in hospice: $17,845

� 7% of patients died in a nursing facility: $21,221

� 5% of patients died in the ER: $7,969

Source: Arcadia Healthcare Solutionshttps://www.npr.org/sections/health-shots/2016/06/15/481992191/dying-in-a-hospital-means-more-procedures-tests-and-costs

‘… intensity of services in the hospital shows a lot of suffering that is not probably in the end going to offer people more quality of life and may not offer them more quantity of life..’

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Advanced Care Planning

� Reduces unwanted hospitalizations — especially during last six months of life

� Reduces costs of care in last two years of life due to elimination of unwanted treatment

� Decreases hospital care intensity in last two years of life

� Reduces inpatient days in last two years of life

� Reduces hospital deaths

� Decreases moral distress of healthcare providers and clinicians working with patient and surrogate end-of-life decision making

Source: Molloy, D. W., Guyatt, G. H., Russo, R., Goeree, R., O’Brien, B. J., Bédard, M., Willan, A. ... Dubois, S. (2000). Systematic implementation of an AD program in nursing homes: A randomized controlled trial. JAMA: The Journal of the American Medical Association, 283(11), 1437-1444.

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ACP Resources

� Care coordination as patients transition from one form of care to another during a progressive, advanced illness can improve care and cut costs

� 74 trained facilitators in Springfield area

� Start the conversation

. For each dollar spent on ACP the cost of healthcare is

reduced by $2

Source: Hammes, B. J., & Rooney, B. L. (1998). Death and end-of-life planning in one Midwestern community. Archives of Internal Medicine, 158(4), 383-390.

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“When health is absent, wisdom cannot reveal itself, art cannot manifest, strength cannot fight, wealth becomes useless, and

intelligence cannot be applied.” ~Herophilus 300 B.C.

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What to Expect

� Healthcare value transformation continues/accelerates

� Patient engagement and consumerism

� New incentives and flexibility

� Payers engage innovators/develop new models

Improve Clinician

Experience

Improve Patient

Experience

Impro

ve Popula

tion

Health

Reduce

Cost

s

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Continued Investments in PHSO

� Post-Acute Care

− Site of care, SNF LOS, HH re-certifications

� Late-Life Care

− ACP / Respecting Choices

− Palliative Care across continuum

� Specialty Care Pathways

− Episodes of care – co-management agreements

− Shared decision-making

− Specialty utilization management

� Unlocking Higher Value Capture

− Medicare Advantage – CoxHealth Medicare Plus

− Cox Health Plans

� Behavioral Health

− Collaborative care model

− PCHH expansion

� Disabled & Medically Frail

− Home-based support

− Fragility fracture program

� Social Determinants of Health

− Predictive analytics

− Workflow integration

− Community partnerships

− APPs

� Clinically-Enhanced Care Management (Real-time data, home telemonitoring)

� Population Management (Mitigating impact of patient churn and underlying trend)

� Provider Engagement and Practice Transformation (Actionable reporting, compensation models)

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Continued Investments in PHSO� Stabilizing or reducing the per capita cost of care for populations will give

organizations the opportunity to be more competitive, lessen the pressure on publicly funded health care budgets, and provide communities with more flexibility to invest in activities, such as schools and the lived environment, that increase the vitality and economic wellbeing of their inhabitants.

� Start with a foundation for population management

� Guiding principles

� Re-organized structure

� Scalable models for managed services for variety of populations

� Create data aggregation team� pulling from multiple data sources

� Actionable data reporting

� Point of care decision support

� Establish a learning system to drive and sustain the work over time

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Discussion

Tracy.Mitchell@coxhealth.com417.269.2917

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