Sources : National Office Statistics Malawi, OSM, IOM, IOM ...
Aligning value incentives in program design IOM Roundtable ...
Transcript of Aligning value incentives in program design IOM Roundtable ...
Aligning value incentives in program design IOM Roundtable on Value & Science-Driven Health Care
March 14, 2012
Rodney C. Armstead, MD FACP
Optum Executive, Collaborative Care
IOM_Armstead 03142012 Final
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum 2 2
Provider-Led Care Models
Risk and Accountability Collaborative
care
Improve financial
management
Lower cost of care
Compliance and reporting
Improve quality of care,
outcomes
Understand population
health
Manage patient and population
risk
Patient engagement
Providers are at the Epicenter of New Models of Care
Science-Driven Clinical
Decisions
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum 5
Care Provider Payment Models
Care Provider Practice Models
Cumulative addressable market
Integrated health system- focus
Optimizing total population health
Global market risk model
Professional services risk model
Episode of illness payment
Bundled services payment
Fee-for-service
Fully-integrated delivery systems
Multi-specialty group
practices
Physician hospital
organizations
Independent practice
associations
Market Change Will Take Many Forms… Community by Community
New value creation for existing solutions; creation of new markets
Virtual community networks
Sole practitioners
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum 6
Goals of the new model
• Macro-level
– Improve the consumer experience
– Improve the overall health of the population
– Improve individual health outcomes
– Decrease cost
• Micro-level
– Seamless connectivity that delivers clinical information/value based options for the provider and patient at the point of care—optimizes science driven decisions
– Transformational consumer & provider engagement
– Sustainable solutions addressing health literacy
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum 7
What does improved quality & cost-effectiveness look like?
• Improved quality
– Sustained & high performance as measured by quality of care and service outcomes, i.e., HEDIS, STAR ratings and other measures exceeding national benchmarks
– Sustained & high consumer & provider satisfaction
– Sustained populations health measures at or above 90th percentile
– Mitigation of gaps in health literacy
– Right care, right place, right time
• Cost-effectiveness
– Zero-extremely low medical cost trend YOY that is sustainable
– Extremely cost effective delivery systems that will result in competitive premiums for individual, private and public payers
– Consistent throughout: provider payment aligned with performance/outcomes
– Value based efficiency metrics
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum 8
Keys to success
• Interconnectivity/inoperability of a network of providers
• HIT infrastructure: eMR, data warehouse, point of care decision tools, shared flow of information across care settings and the ability to populate the measures that prove that value was achieved
• Consensus standards by which performance is measured with complete transparency
• Alignment of measures between CMS, States and Commercial purchasers given the fact that most physicians are multi-payer
• Regardless of the clinical model: a physician-led culture is essential/critical
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum 9
Specialist (FFS & High Quality)
Collaborative Practice Features
SNF & Transition
Facilities
Specialist (i.e., Capitated
& High Quality)
Hospital E.R
Hospitalist
Actively managed care
coordination by a
Clinical Team of
physicians and nurses
PA NP
MD
NP MD
PA
NP
MD
Delivery System Design (Practice Model)
• Primary Care Practice: contracted with aligned payment | supported with data and clinical support network |
close integration and coordination
• Care Center: clinic and infrastructure focused on chronic and complex patients and after hours support
• Hospital and Hospitalist: contracted and supported with embedded Transition Coach
• Specialists: right sized network, prioritized based on quality (performance + patient satisfaction) and
economic criteria
PA
NP
MD
PA
Primary Care Providers
Employed
Contracted
NP
PA
MD
PA
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum 10
Earning loyalty and trust though an innovative, breakthrough service experience, connecting our patients and their physicians
Collaborative Technology
InformAction
People that Care to Act
Incentives for Improving Health
Administration Assistance
Billing/Reimbursement
Claims Processing
Patient Scheduling
Prescription Refills
Clinical Community
Physicians/Clinicians
Case Managers
Health Coaches
Home Care/ Remote Monitoring
Linking Information
Health and Drug History
Wellness Education
Transportation
Life Transitions/ Social Assistance
Care Center
Delivery System Design (Service Model)
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum 11
Delivering Care and Services to Patients
Preventative Care
Telehealth| Primary Care
Retail Clinics | Specialists
Senior/Community Centers | E-visits
| Mobility Assistance
Remote Monitoring | Infusion Therapy
Transition Services | House Calls
Institutional Patient Mgmt²
Chronically-Ill Mgmt³ | Admission To Home
Palliative and Hospice Care5
Ambulatory | Emergency Room | Urgent Care
Connected, intelligent and aligned health
communities meeting each patient’s
needs
2. Skilled Nursing; 3. Nurse Practitioner Home Visits; 4. 12-18 Months to Live; 5. <6 Months to Live
Local Integrated
Delivery Systems
Coordinated
Care at Home
Customized care solutions delivered
before or after a medical event
Interconnectivity Interoperability
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum 12
Practical Application of Coordinated IPAs
• Care system where doctors, medical information, care plans and medication history all connect together.
• Providing quality medical care that is safe, effective, efficient, timely, personalized, and equitable for its members.
• Ability to have a multi-payer platform
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum 13 13
IPA Technology Integration
Physicians
Urgent Care
Home Health
Care Teams
Physician Assistants
Nurse Practitioners
Electronic Medical Record
• Tasking • Referral integration
• E-Rx
Digital Imaging
• Radiology • Integrated into EMR
• Cardiology
External Connections
• Quest Lab • Referrals – specialists
• Pharmacies
Web-based Self-Service
• Appointment scheduling • E-visits
• Problems • Portable medical record
• Rx renewal • Results
• Vitals • Advanced directive
Custom Clinic Tools
• Kiosk check-in
• Skype- like customer service Kiosk
• Patient education
• Patient medical profile (wrapper) for triage
Patient Notifications
Automated phone calls and email
• Appointment reminders
• Rx notifications
• Orders/results notifications
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum 14
Practical Application of Coordinated Post Acute Care
• Providing innovative, provider-driven, patient centric healthcare solutions designed for high risk, medically complex populations
• Delivering the right care, to the right patients, at the right time, resulting in improved quality and lower health care costs
• Proven success and cost savings
– Impact on Acute Admits
– ER Readmission Rates
– Cost of End of Life Care
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum 15
High Risk Dual SNP Members – Acute Admits/1,000 Comparison
1,6231,690
1,4651,567
1,4031,529
1,975
1,608
633715
633 677
354
630502
593 563
-
500
1,000
1,500
2,000
2,500
Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 7 Month
Avg.
Combined
Next 12
Months
Control Group INSPIRIS Treatment Group
Control Group Treatment Group
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum 16
High Risk Medicare Advantage Members Medication Management
Pre Program Program
2.0
6.0
11.5
2.7
4.3
5.6
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
3 or Less 4 to 8 9 or More
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum 17
High Risk Medicare Advantage Members End of Life Care
Enrolled High Risk (non-enrolled) Non-enrolled
End of Life PMPM Cost
$3,869
$4,129 $4,176 $4,689
$5,465
$6,427
$6,930 $7,424
$7,924
$8,691
$10,076
$11,799
$3,717
$4,154 $4,723
$5,550
$6,900
$9,468
$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
$14,000
Month 6 Month 5 Month 4 Month 3 Month 2 Month 1
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum 18
High Risk Age, Blind & Disabled Medicaid Members
• Strong reduction in acute admissions/K compared to baseline
• Reducing from 2,400 Admits/K to an average of 1,090/K
• Average 30 day readmission rate dropped to 23% from 32.7%
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum 19
Transitions Reduction in Readmissions
Medicare Advantage Members
Average Medicare Advantage Plan
With Transition
Program
21.0% 13.9%
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum 20
Sub-Acute SNF Transitions – Medicare Advantage Members Skilled Length of Stay Improvement
17.50 17.50 17.50 17.50 17.50
14.0014.41 14.34 14.13 13.98
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
16.00
18.00
20.00
2006 2007 2008 2009 2010
Baseline ALSO Program ALOS
Reduction of 2.97 to 3.52 Days Saved
Confidential property of Optum. Do not distribute or reproduce without express permission from Optum 21
Barriers to future success
• Reconciling the confusing landscape of competing performance measures across the system
• Sub-optimal HIT inter-connectivity and inter-operability
• Adequate capital needed for practice transformation
• Gap between fee-for-service and value base contracting that is needed to fully drive change
Rodney C. Armstead, MD FACP Optum 77 Water Street, 14th floor New York, New York 10005 212-898-8498 [email protected]