utah hospital aug 2014

© 2014 IBM Corporation

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Paul Grundy MD, MPH - IBM Director, Healthcare Transformation August, 2014

Utah Hospitals Better Care, Reducing Costs, Improving service

Population Health Patient Centered Medical Home

© 2014 IBM Corporation 2

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Paul Grundy MD MPH Bio

• “Godfather” of the Patient Centered Medical Home• IBM Global Director Healthcare Transformation • President of PCPCC • Member Institute of Medicine• Member Board ACGME • Professor Univ. of Utah Department Family Medicine

• Winner NCQA national Quality Award • A Leader of MOH level taskforce primary care transformation 8

nations: USA, Canada, New Zealand, Australia, Holland, Denmark, UK, Belgium,

• Univ. of California MD, John Hopkins Trained


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PopulationHealth

System Integrator

PatientExperience

The System Integrator

Creates a partnership across the medical neighborhood

Drives PCMH primary care redesign

Offers a utility for population health and financial

management

Per Capita Cost

Public Health

Away from Episode of Care to Management of Population

Hospital Hospital

Community Health Community Health


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4

0

1000

2000

3000

4000

5000

6000

7000

1980 1983 1986 1989 1992 1995 1998 2001 2004

United StatesGermanyCanadaFranceAustraliaUnited Kingdom

Average health spend per capita ($US PPP)

How do you start to fix the foundational issue around why our healthcare system is so expensive and yet so broken??

Source: K. Davis, C. Schoen, S. Guterman, T. Shih, S. C. Schoenbaum, and I. Weinbaum, Slowing the Growth of U.S. Health Care Expenditures: What Are the Options?, The Commonwealth Fund, January 2007, updated with 2007 OECD data


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Current Payment Systems Penalize Primary care Prevention Quality and Reward Volume We have discover the enemy --- we buy garbage!!!! IBM other large Buyers are demanding change in that (BIG TIME)

PreventableCondition

ContinuedHealth

HealthyConsumer

NoHospitalization

Acute Care Episode

Efficient, Successful Outcome

Complications,Infections,

Readmissions

High-CostSuccessfulOutcome

$Fee-for-Service PaymentPays More for Bad Outcomesand Less When People Stay Healthy

IBM paying first $$ primary care!!


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Reason IBM pays 1st dollar primary care

“Not surprisingly, those patients with the strongest relationships to specific primary care physicians were more likely to receive recommended tests, medication adherence and preventive care.

In fact, this sense of connection with a single doctor had a greater influence on the kind of preventive care received than the patient’s age, sex, race or ethnicity.”

Patient–Physician Connectedness and Quality of Primary Care Steven J. Atlas, MD, MPH; Richard W. Grant, MD, MPH; Timothy G. Ferris, MD; Yuchiao Chang, PhD; and Michael J. Barry, MD 3 March 2009 | Volume 150 Issue 5 | Pages 325-335


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“We do heart surgery more often than anyone, but we need to, because patients are not given the kind of coordinated primary care that would prevent chronic heart disease from becoming acute.” -- George Halverson’s (CEO Kaiser) from “Healthcare Reform Now


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36.3% Drop in hospital days32.2% Drop in ER use12.8% Increase Chronic Medication use -15.6% Total cost 10.5% Drop Inpatient specialty care costs 18.9% Ancillary costs down 15.0% Outpatient specialty down

Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence from Prospective Evaluation Studies in the US - PCPCC Oct 2012

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Creating Value Through Patient Centered Medical Homes

October 22, 2009

Bob Kocher, MDNational Economic CouncilSpecial Assistant to the President


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MOVING TOWARDS A MORE COORDINATED SYSTEM

11

Cooperating in new efforts to better coordinate care

• Accountable Care Organizations (ACOs)

• Community health teams

• HIT

Working with innovative reimbursement structures

• Bundled payments

• Expanded pay-for-Quality

• Readmission incentives

• Outlier reductions

Improving health outcomes

• Prevention (primary and secondary)

• Chronic disease management

• Patient engagement and education

• Data transparency

Patient Centered

Medical Homes quality

improving/value creating systems


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HEALTH INSURANCE REFORM WILL IMPROVE THE WAY CARE IS DELIVERED FOR ALL AMERICANS

12

•Primary care has a critical role to play in reform

•Health insurance reform will facilitate adoption of advanced primary care models (PCMH)

Changes to the delivery system

•Incentives quality not quantity of medical care

•No cost sharing for preventive care

•Better coordinate care for patients with chronic diseases

•Ensure patients receive clinically recommended treatments and follow-up

•Reduce duplicative testing and rehospitalizations

•Integrate with community health resources to provide more holistic patient care

•Expand coverage and access


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Maryland July 2014 -- CareFirst saved $267 million with its medical home

• 11 percent fewer days in the hospital • 8 percent fewer hospital readmissions.

http://www.fiercehealthpayer.com/story/medicaid-can-reap-rewards-medical-homes/2014-07-15


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Rural New York July 2014

Costs for Medicaid patients dropped from $334 to $266, according to a recent “risk

adjusted” analysis.

http://poststar.com/news/local/medical-home-program-gains-traction/article_5811380c-2ee9-11e3-8548-001a4bcf887a.html


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•9.9 percent lower rate of adult ER visits•27.5 percent lower rate of adult ambulatory care sensitive inpatient stays•11.8 percent lower rate of adult primary care sensitive ER visits•8.7 percent lower rate of adult high-tech radiology usage•14.9 percent lower rate of pediatric ER visits•21.3 percent lower rate of pediatric primary-care sensitive ER visits

24 July 2014 Michigan Blues’ patient-centered medical home program shows statewide transformation of care YEAR 6

4,022 primary care doctors at 1,422 practices around the state in its sixth year of operation. These practices care for more than 1.2 million BCBSM members


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44% reduction in hospital costs

21% reduction in overall medical costs.

160 PCMH practices Pennsylvania from 2009 to 12

Number of patients with poorly controlled diabetes declined by 45%

44% reduction in hospital costs

21% reduction in overall medical costs.

160 PCMH practices Pennsylvania from 2009 to 12

Number of patients with poorly controlled diabetes declined by 45%

http://www.ajmc.com/publications/issue/2014/2014-vol20-n3/Medical-Homes-and-Cost-and-Utilization-Among-High-Risk-Patients#sthash.qR8uWb4t.dpuf

http://www.ajmc.com/publications/issue/2014/2014-vol20-n3/Medical-Homes-and-Cost-and-Utilization-Among-High-Risk-Patients#sthash.qR8uWb4t.dpuf

PCMH Pennsylvania June, 2014

Conclusions: PCMH practices had significantly reduced costs and utilization for the highest risk patients, particularly with respect to inpatient care.


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Ogden UT ,

USA 2012


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Smarter CareMobileFirst Patient Consumer


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PreventiveMedicine

MedicationRefills Acute Care

Nursing

Test Results

Master Builder

DOCTOR

Source: Southcentral Foundation, Anchorage AK

BehavioralHealth

CaseManager

MedicalAssistants

Chronic DiseaseMonitoring

Practice transformation away from episode of care


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MedicationRefills

ChronicDisease

MonitoringTest

Results

AcuteCare

PreventiveMedicine

Point of Care Testing

Acute Mental Health

Complaint

ChronicDisease

ComplianceBarriers

HealthcareSupport

Team Behavioral Health

MedicalAssistants

CaseManager Provider

Source: Southcentral Foundation, Anchorage AK

PCMH Parallel Team Flow Design: the glue is real data, not a doctor’s brain


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Today’s Care PCMH Care

My patients are those who make appointments to see meMy patients are those who make appointments to see me

Our patients are the population community Our patients are the population community

Care is determined by today’s problem and time available todayCare is determined by today’s problem and time available today

Care is determined by a proactive plan to meet patient needs with or without visits

Care is determined by a proactive plan to meet patient needs with or without visits

Care varies by scheduled time and memory or skill of the doctorCare varies by scheduled time and memory or skill of the doctor Care is standardized according to

evidence-based guidelinesCare is standardized according to evidence-based guidelines

Patients are responsible for coordinating their own carePatients are responsible for coordinating their own care

A prepared team of professionals coordinates all patients’ careA prepared team of professionals coordinates all patients’ care

I know I deliver high quality care because I’m well trainedI know I deliver high quality care because I’m well trained We measure our quality and make

rapid changes to improve itWe measure our quality and make rapid changes to improve it

It’s up to the patient to tell us what happened to themIt’s up to the patient to tell us what happened to them

We track tests & consultations, and follow-up after ED & hospitalWe track tests & consultations, and follow-up after ED & hospital

Clinic operations center on meeting the doctor’s needsClinic operations center on meeting the doctor’s needs

A multidisciplinary team works at the top of our licenses to serve patientsA multidisciplinary team works at the top of our licenses to serve patients

Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma


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Superb Access to Care

Patient Engagement in Care

Clinical Information Systems, Registry

Care Coordination

Team Care

Communication Patient Feedback

Mobile easy to use and Available Information

Defining the Care Centered on Patient


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Trajectory to Value Based Purchasing: Achieving Real Care Coordination and Outcome Measurement

Source: Hudson Valley Initiative


Smarter CarePayment reform requires more than one method, you have dials, adjust them!!!

“fee for health” fee for value “fee for outcome”“fee for process” “fee for belonging“fee for service” “fee for satisfaction”

“fee for health” fee for value “fee for outcome”“fee for process” “fee for belonging“fee for service” “fee for satisfaction”


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Give me enough medals and I'll win you any war' Napoleon Bonaparte – not just the $Green$ that brings JOY

The Science of Rewards, incentives


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% Total Healthcare

Spend

% of Members

Those who are well or think they are well

Those with chronic illness

Those with severe, acute illness or injuries

Benefit Redesign - Patient Engagement Different Strategies forDifferent Healthcare Spend Segments


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IBM’s Strategy Moves Costs From Below Market to Market Leader

Best in market purchasing strategy Redesigned plan mix to use PPO

model Employee-centric allocation of IBM

investment with dependent subsidy reduced

Investments in prevention, primary care and chronic disease management

Employee cost sharing keeps pace with inflation

Award-winning wellness strategy providing support for healthy living; onsite screenings and immunizations

Source for benchmarks: Average of survey results from Kaiser Family Foundation, Hewitt Associates and Towers Perrin

4.8%

9.7%

4.5%

6.6%

10.6%

6.4%7.0%

4.9%

2.2%

5.6% 4.6%

3.7%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

11.0%

12.0%

20042005 2006 2007 2008

2020099

Net

IBM

Med

ical

Tre

nd

Benchmark Net IBM Trend

$1B Saved in 6 Years


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30 © 2009 IBM Corporation6

IBM Population Risk Has Moved Toward Improved Health

Wellness programs have had a dramatic impact on the health of our employees

– Percentage of employees with high health risks reduced by 55%

– Percentage at low risk increased by double digits

Reduction in health risks translates into health claims cost reduction

– Represents an almost $300 reduction in per employee costs or a $29M savings

2004 – 2007 Health Risk Assessment Participation

*$392M = 2007 dollars applied to 2004 health risk profile.**Total costs based on 103K total self-insured population and represent employee costs only (not including dependents)

Projected 2007 spend with no health risk improvement

Actual spend

$7,555

$4,638

$2,660

$392M* $363M**$29M (7%) difference

55.4%68.3%

31.8%

26.0%

12.8%5.7%

0%

20%

40%

60%

80%

100%

2004 Profile 2007 Profile

% o

f A

ll H

RA

Par

tic

ipan

ts

High Risk (4+ risks)

Medium Risk (2-3risks)

Low Risk (0-1 risk)

Shift in Health Risk Profile = Savings in Healthcare Claims Costs

Note: Includes ALL participants each year, NOT MATCHED SAMPLES

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% o

f A

ll H

RA

Pa

rtic

ipan

ts

High Risk (4+ risks)

Medium Risk (2-3 risks)

55.4%59.2%

64.8% 68.3%

31.8% 30.2%28.7% 26.0%

12.8% 5.7%10.6% 6.5%

2004 2005 2006 2007(N=54K) (N=70K) (N=73K) (N=75K)

Low Risk (0-1 risk)

$363M$369M

$383M

$401M$398M$395M

$392M

$340

$360

$380

$400

$420

2004 2005 2006 2007

IBM

Med

& R

x Pa

id C

laim

s Co

sts

($M

's)

(Cal

cula

ted

base

d on

200

7 do

llars

)

2005 2006 20073 Year Total

Est. savings between IBM health risk improvement &

expected risk increase$12M $29M $38M $79M Total

Wellness programs have had a dramatic impact on the health of our employees ‘04 to ’07

High health risk population reduced 55%Low health risk population increased 23%

Reduction in health risks translates into savings in health claims costs compared to expected trends with no wellness interventions

$279M estimated savings for 2004 to 2013 period

Expected cost increase with no IBM population

health risk improvement*

With actual IBM population health risk

improvement**


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Public Health Prevention

Specialists

PCMH 2.0 in Action

Community Care Team

Nurse CoordinatorSocial Workers

DieticiansCommunity Health Workers

Care Coordinators

Public Health Prevention HEALTH WELLNESS

Hospitals

PCMH

PCMH

Health IT Framework

Global Information Framework

Evaluation Framework

Operations

A Coordinated Health System

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2009 2010 2011 2013 2014Percentage of Vermont population participating 6.7% 9.8% 13.0% 42.0% 86.0%

Participating population 42,179 61,880 82,332227,04

5654,852 # Community Care Teams 2 3 4 6 11


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The New Yorker: The Cost Conundrum June 1st 2009

• When you look across the spectrum from Grand Junction to McAllen you see A threefold difference in the costs of care—

• you come to realize that we are witnessing a battle for the soul of American medicine. Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.

• The lesson of the high-quality, low-cost communities is that someone has to be accountable for the totality of care. Otherwise, you get a system that has no brakes. You get McAllen.

• The foundation of this is at the Micro level someone has to be Accountable for your care -- that is the PCMH in most of the civilized world !!!

• primary care doctors per 100,000 Grand Junction, 106, McAllen has just 45

• OR WHERE is the ADULT supervision!!!


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Healthcare Will Transform

Data Driven

Every person has a plan

Team based

Managing a population down to the person

.


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Hospital

Payer

EmployerCommunity

Government

Primary Care

Provider

Other Caregivers

Pharmaceutical Manufacturers

Nurse

Specialists

Social Worker

PCMH

Patient

The PCMH model impacts stakeholders across the continuum of care

Pharma: Improved communication platforms and relationships with healthcare providers, patients and payers; increased sales through improved patient identification, diagnosis, and treatment; recognized as a key player in the patient health delivery value chain

Payer: Improved member and employer satisfaction, lower costs, opportunity for new business models

Employer: Lower healthcare costs, more productive workforce, improved employee satisfaction

Government: Lower healthcare costs, healthier population

Patient: Better, safer, less costly, more convenient care and better overall health, productive long-term relationship with a PCP

Primary Care Provider: Increased focus on the patient and their health, greater access to health information; higher reimbursement; more PCPs

Specialists: Better referrals, more integrated into whole patient care, better follow up less rehospitalizations

Hospital: Lower number of admissions and re-admissions for chronic disease patients; able to focus on acute care issues


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1. Pursue Electronic Patient Management and engagement rather than Electronic Patient Records 2. Bring to bear upon every patient encounter what is known rather than what a particular provider knows. 3. Make it easier to do it right than not to do it at all. 4. Continuous performance improvement. 5. Infuse new knowledge and decision-making tools throughout an organization instantly.


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6. Establish and promote continuity of care with patient education, information and plans of care.

7. Enlist patients as partners and collaborators in their own health improvement.

8. Evaluate the care of patients and populations of patients longitudinally.

9. Audit provider performance based on the Consortium for Physician Performance Improvement Data Sets.

10. Create multiple case-management tools which are integrated in an intuitive and interchangeable fashion giving patients the benefit of expert knowledge about specific conditions while they get the benefit of a global approach to their total health


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Practices Features -- - Emphasis on care coordination and system navigation, System Integrator, PCMH role for family physician in integrated system - Big push on population health management - Care teams with PCP + a variety of other professions, e.g., nursing, pharmacy, public health and mental health.

Technology Use - Better population health data stemming from centralized data based EHR through integrated system. - Adoption of telemedicine, Establish Primary Care Technology Center (PCTC), a research and training entity, to fuel adoption of efficacious technology in practice, patient engagement tools. Modern, flexible, sophisticated system, developed in partnership with technology providers. -Multi-modal communication w/ patients .


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Building a Workforce -- Training in the use of population health management, data management and public health tools - Dual degrees – MD + MBAs, MPHs - .Add’l training in interprofessional collaboration, EHR data usage, and integrated practice management.

Research Focus -- Conclusive evidence about system wide quality improvement and cost savings of robust primary care.- Rise of Continuum-Based Research Networks, applied research efforts to improve clinical pathways. - Research builds case for reductions in Total Cost of Care (at system level), research into technologies most inpactful on Triple Aim. - FM becomes trusted source of best practices to meet Triple Aim, .Focus on issues that relate to patients owning their own health through patient experience and engagement research


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Collaboration -- - Family medicine’s partnership with payers and the integrated systems, to exchange ideas about how to best deploy family physicians and represent their colleagues’ interests to these systems - Subspecialists – to ensure great working relationships within systems. - Primary care professionals – to achieve the best possible outcomes in service of Triple Aim. Payers, particularly CMS – to ensure success of alternative payment pilots.- Primary Care Nurse Practitioners (to work together in pursuit of expanded role of Primary Care, Technology manufacturers) to provide advice on how to improve technology in use by FPs,

Key Investments -- Curricular overhaul and research effort to prepare residents for work in integrated systems, tools for data being made into actionable information in population management, advance clinical decision support


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Thank you


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A comprehensive approach helps reduce costs while improving care

Apply new insights from interactions and outcomes

to enable continuous transformation

LEARNING

Identify and influence individuals and populations, and recognize

intervention opportunities

INTERVENTION

COORDINATIONDeliver care and monitor progress

across clinical and social requirements

COLLABORATIONAssess and engage individuals and stakeholders to drive individualized care plans

Drive evidence-based andstandardized care planning

KNOWLEDGE

WELLNESS

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Trademarks and notes

© IBM Corporation 2014• IBM, the IBM logo, ibm.com, and Cúram are trademarks or registered trademarks of International Business

Machines Corporation in the United States, other countries, or both. If these and other IBM trademarked terms are marked on their first occurrence in this information with the appropriate symbol (® or ™), these symbols indicate U.S. registered or common law trademarks owned by IBM at the time this information was published. Such trademarks may also be registered or common law trademarks in other countries. A current list of IBM trademarks is available on the Web at “Copyright and trademark information” at ibm.com/legal/copytrade.shtml.

• Other company, product, and service names may be trademarks or service marks of others.• References in this publication to IBM products or services do not imply that IBM intends to make them available in all

countries in which IBM operates.


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Objectives

1) Participant will understand/be able to discuss the important trend of PCMH in health care 2) Participant will understand/be able to explore the rationale and supporting evidence for PCMH 3)Participant will understand/be able comprehend the impact on patients, providers and payers

Disclosure – I am a full time Employee of IBM –IBM and other PCPCC executive member companies have supported by talks on PCMH.

utah hospital aug 2014

Healthcare

multidisciplinary

track tests

lower healthcare

health risks

population

triple aim

ed amp

prepared team