Population Health ManagementThe response to,

• Fixing Health Care’s Broken System

• Richard F. Multack DO, FOCOO, MBA

•Vice President of Medical Management

•Advocate South Suburban Hospital

Please don’t worry

3

The Way We Were

How did we get here?•1. Unsustainable growth of health cost

•2. Growing lack of access to healthcare•3. Disparities in care

Who’s driving up U.S. healthcare costs? A recent study by Harvard professors and colleagues revealed that the culprits may be “cowboy doctors”—physicians who provide intensive, unnecessary, and often ineffective patient care, resulting in wasteful spending costing as much as 2 percent of the nation’s Gross Domestic Product—hundreds of billions of dollars annually. 

We were Confused

We lacked direction

Sometimes… you need to pick a different road

“The best way to deal with the future is to create it”

Abraham Lincoln

What have we done?• 1. HITECH ACT (American Recovery and Reinvestment Act of 2009)• 2. Patient Protection and Affordable Care Act of 2010

• Pay 4 Performance• Patient Centered Medical Home• Payment Bundling• Shared Savings / ACO• Value Based Purchasing• Hospital penalty for Readmissions, and other quality issues such as HACs

Medicare Physician Payment 

• Medicare Access and CHIP Reauthorization Act of 2015• Replaces the “dreaded” Sustainable Growth Rate

• Beginning in 2019 establishes two payment tracks for physicians

• Those in alternative payment models (APM)

• All others in MERIT‐BASED INCENTIVE PAYMENT SYSTEMS (MIPS)

Merit‐Based Incentive Payment System (MIPS)

• Sunsets existing payment programs: PQRS, VBM, EHR meaningful use

• CMS will incorporate these measures and develop methodology for assessing performance

• Physician performance will determine annual payment adjustor

MIPS

• There will be a Composite Threshold Performance Scale (0‐100)• The system will award bonuses and impose penalties based on whether physicians score above or below a certain threshold on quality measures, including meeting the requirements for the meaningful use of health IT. 

• Reimbursement will actually be based on;• Meaningful Use• Quality measures• Clinical Practice Improvement Activities

MIPS

• Four (4) performance categories• 25Pts MU of CHERT• 15Pts Clinical Practice Improvement• 30Pts VBM‐measured quality• 10Pts VBM‐measured resource use

• First Performance Measure Year ‐2017• First likely payment adjustments 2019

External Pressure on PhysiciansMD and Hospital Quality Reports

Care Coordination

Team Medical Necessity

Value Base

Purchasing

PSIs

Core Measures

ComplianceFraud Abuse

RAC

2 MIDNIGHTRULE

E&M Pro feesDenial related

claims

ICD-9-CMICD-10

POAHACs

PreventableReadmission

Complications

On top of all that then they gave us ICD‐10

$661 M community benefit

M community 

Key Market Dynamics• Provider consolidation• Dominant health plans• Narrow networks emerging• Revenue - utilization and price• Cost pressures

• Anthem has agreed to acquire Cigna in a $54 billion merger of health insurance giants.

The companies said that Anthem, Inc., a Blue Cross and Blue Shield insurer, would buy all of Cigna Corp.'s shares in a cash and stock transaction.

The latest step in a striking consolidation of the insurance industry would leave only  three major players.

Earlier this month, Aetna struck a deal to buy Humana for $37 billion.

Strong Alignment• Values• Top decile safety and quality• Strong brands • Highly integrated• Large employed medical groups • Strong management and governance • Excellent teaching and research • Double A ratings

Changing Business ModelProviders traditionally generate revenue by:

• Maximizing rates• Maximizing volumes (churning)

• Which is changing to a new model• Taking financial risk for managing the

health of a population, lowering costs and serve a greater number of unique patients

Advancing Commercial Approach

•Extension of Blue Cross shared savings and global capitation contracts

•Shared Savings ACO contractsUnitedCIGNAOthers

Medicaid Managed Care• Illinois requires 50%+ of Medicaid population be enrolled in: Accountable Care Entities (ACE)Medicaid HMOs Cook County Demonstration

•Medicaid ACE is fee for service with a care management fee until Jan. 1, 2016

Why did they do it?

•The overarching purpose of these changes is to move away from fee‐ for‐ service , which is regarded as a major driver of the nations health cost

•To a model of greater responsibility and accountability. This approach  is called Population Health management

What is it?

• Population Health management is defined as, controlling the health outcomes of a group of individuals.

• This includes,• Public health intervention• Social environment

• Income• Education• Employment• Social support• Cultural factors

What is it?

• Includes,• Aspects of the physical environment

• Urban design• Clean air• Clean water

• Genetics• Behavioral Health

• Psychiatric conditions• Addiction

Skilled Nursing Facility

Hospital -Outpatient

Urgent Care Ctr

Retail Clinic

Employer Clinic

• Day Surgeries• Emergency• Clinic visits• Observation• Hospital‐Based ancillary services

OutpatientAmbulatory

Free-standing Diagnosis Center

End Stage Renal Disease

OP Facility/ Comprehensive OP Rehab Fac.

HospitalPre Hospital Post Acute Care

Home Hospice

Indian Health Services

Community Mental Health Clinic

Inpatient

Hospital –Inpatient

Psych

Inpatient Rehab

Home Healthcare

Home Health Agency

Physician Practices Ambulatory

Surgery Ctr

Fed Qualified HC

Critical Access Hospital

Outpatient

Rural Health Clinic

Hospice

Critical Access Hospital Inpatient

Population at Risk

The Continuum of Care

PhysicianOfficeClinic

Physician Evaluation and Management

Goal of Population Health Management

• The goal of population health management is to keep a patient population as healthy as possible, minimizing the need for expensive interventions such as emergency room visits, hospitalizations, imaging , testing and unnecessary procedures.

• Although focused on the sickest patients initially PHM addresses the preventive and chronic care needs of the population.

• We know that distribution of healthcare risk changes over time, the object is to modify the factors that make people sick or exacerbate their illness. 

ECM Inpatient CM

ECMOutpatient CM

Post‐Acute‐Post acute SNF Network/Model‐Transition coaches‐Advocate At Home‐Palliative Care

Primary Care Access‐Primary Care Access, Team Model of Care

Strong Relationship and Communication

ECMOutpatient CM

Care Management Supports the Patient Continuum…

Methodology

•Data Collection, storage and management = EMR•Population Monitoring and Stratification = Statisticians•Patient engagement• Team based intervention•Measuring outcomes

Methodology

•Population health management requires healthcare providers to develop new skill sets and new infrastructure for delivering care

Reimbursement Today 

2020 Outlook

From Fill the Hospital to Empty the Hospital

POPULATION MANAGEMENT

So how are we going to actually manage the population?• 24/7 Access to office or ambulatory acute care setting• Same day appointments• Medical Home• Narrow networks• Integrated care – keep it in the system• Clinical Effectiveness‐carve out waste

• Decreasing pre‐op testing• Stopping unnecessary and obsolete lab testing• Stopping unnecessary imaging and procedures• Appropriate use of blood transfusions• Standardization of equipment and procedures such as total hips leveraging economies of scale for better vendor pricing

So how are we going to actually manage the population?• 24/7 Access to office or acute care setting• Same day appointments• Medical Home• Narrow networks• Integrated care – keep it in the system• Extensive social support

• Care management• Social work• Integrated home health• Integrated PAN network• Behavioral health• Patient engagement

Outpatient Care Management

•Dedicated Outpatient CMs

•Multi‐condition centers

Emergency / Acute Care 

Management• Inpatient CMs• ED CMs• Hospitalists

Post‐Acute Network•SNF Post Acute Network

•Advocate At Home•Palliative Care

Transitions

Patient/PCP

Patient/Family Education and  

Support

Community Agencies/Programs

ACO Value Structure: Wrap‐Around Care ContinuumAligned Goals, Strong Relationship and Communication = Patient/PCP Value

SummaryConclusions

Better life stylePreventive careAppropriate careIntegrated careHome CareSkilled nursing careAppropriate end of life care

References• Advocate Health Care, MPAK‐ “ Health Care’s Perfect Storm’ Leadership Development Institute Quarter 1 2015

• Advocate Health Care, Physician Leadership Development Day 2015, June 19, 2015, “Strategies to Whether The Storm” , Lee Sack, MD CMO Advocate Health Care

• “The Changing Face of Medicine‐“What’s In It For Me” Richard F. Multack, DO, VPMM, ASSH (2013)

• “The Changing Face of Medicine‐2014 and Beyond” Richard F. Multack, DO, VPMM ASSH (2014)

• Kindig D, Stoddart G. What is population health? (http://www.ajph.org/cgi/reprint/93/3/380.pdf) American Journal of Public Health 2003 Mar;93(3):380‐3 Retrieved 2015‐5‐7

• Howe, Rufus, and Christopher Spence. Population health management: Healthways’ Pop Works (http://www.healthways.com/assets/0/98/E4CDDEDB‐5004‐4E74‐A5C9‐E1973F5ABC05.pdf). HCT Project 2004‐07‐17, volume 2, chapter 5, pages 291‐297. Retrieved 2015‐5‐7

• Coughlin JF, Pope J, Leedle BR. Old age, new technology, and future innovations in disease management and home health care (http://web.mit.edu/agelab/news_events/pdfs/home.health.care.pdf) Home Health Care Management & Practice 2006 Apr; 18 (3):196‐207. Retrieved 2015‐5‐7

• DMAA: The Care Continuum Alliance. Publications. Population Health management (http://www.dmaa.org/pubs_dm_journal.asp) Retrieved 2015‐5‐7

• Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ (May 27, 2006) “Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data” (http://www.fic.nih.gov/news/fogarty/2006/depp_lancet_367.pdf) (PDF). The Lancet 367 (9524): 1747‐1757. Doi:10.1016/SO140‐6736(06)68770‐9 

• (http://dx.doi.org/10.1016%2FS0140‐6736%2806%2968770‐9). PMID 167321270 (http://www.ncbi.nlm.nih.gov/pubmed/16731270).

• Congressional Budget Office, May 2013” Estimates of the Effects of the             Affordable Care Act on Health Insurance Coverage

• CDC/NCHS “ National Ambulatory Medical Care Survey 20009‐2010 Primary Care Shortages could be Eliminated Through Use of Teams, Nonphysicians and Electronic Communication‐ Health Affairs 32 1 Jan 2013

• Michael E. Porter and Thomas H. Lee, “The Strategy That Will Fix Health Care,” HBR October 2013

• Kaiser Family Foundation, “2012 Employer Health Benefits Survey”