Population Health Management at Partners HealthCare · 2016-10-11 · Population Health Management...

Population Health Management

at Partners HealthCare

Timothy Ferris, MD, MPHSVP, Population Health Management, MGH, MGPO and Partners HealthCare

Integrated Care ConferenceOctober 11, 2016

Center for Population Health Confidential – do not copy or distribute

The Ecology of Medical Care- Historic View

White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med 1961;265:885-892

Monthly Prevalence of Illness and the Provision of Medical Care.

Adult population at risk

Adults reporting symptoms

Adults consulting a physician 1 or more times per month

Adults admitted to hospital 1 or more times per month

Adults referred to academic medical center per month

Adults referred to another physician per month


The Ecology of Medical Care- Current View

Monthly Prevalence Estimates of Illness and the Provision of Medical Care.



Adults visiting alternative medical care

Adults receiving home health care

Adults visiting outpatient clinic

Adults considering seeking medical care

Adults visiting MD office

Adults visiting ED

Adults hospitalized

Adults hospitalized at AMC

Adapted from Green, LA, Fryer GE, Yawn BP, Lanier D, Dovey SM, Green LA. The Ecology of Medical Care Revisited. N Engl J Med 2001; June 28, 2001


The Ecology of Medical Care- Future State



Adults receiving home health care

Adults visiting outpatient clinic

Adults considering seeking medical care Adults visiting MD office

Adults visiting EDAdults hospitalized

Adults hospitalized at AMC

Adults consulting physicians through e-visits

Adults consulting physicians through virtual visits

Adults receiving home observationAdults receiving tele-monitoring

Adapted from Green, LA, Fryer GE, Yawn BP, Lanier D, Dovey SM, Green LA. The Ecology of Medical Care Revisited. N Engl J Med 2001; June 28, 2001

Adults admitted directly to SNF

Adults seeking palliative care

Monthly Prevalence Estimates of Illness and the Provision of Medical Care.

Center for Population Health Confidential – do not copy or distribute 5

• The number of adults reporting symptoms has remained unchanged but the breadth and specificity of services has grown dramatically.

• Payment system creates the ecology of medical services.

• FFS system requires highly specified services- difficult to customize to patient needs and still get paid.

• Risk contracting does not require specification of services.

Key takeaways from the changing health care ecology.


Health care “crowds out” other spending

Massachusetts, FY 01 vs. FY 14, in billions


What we’re facing…

• The market is returning to techniques used during managed care in the 1990s [closed networks, budget-based risk, cost sharing, restriction of choice] – will this generate the same backlash?

• But...

• The economic imperative is stronger

• Government is proactive (Massachusetts 3.6% cap on healthcare cost growth)

• Rate of change is slower (caps on increases, not cuts)

• And we have…

• Better health IT and data for population management

• Strategies and tactics that we know will improve care and reduce costs


Implications for providers

Challenges

1. We need tactics that will be successful under any new payment model

2. How to make external incentives meaningful to our clinicians

• Must not undermine trust

3. Moving at the right pace

Too fast: we will lose the docs in the rush to implement – MDs attitude often creates the patient's attitude (managed care backlash)

Too slow: will mean not succeeding under the contracts and forcing more blunt solutions


Telling our story

~48 PHM publications since 2012

• Highlights

• A Modified “Golden Rule” for Health Care Organizations (2012) Mayo Clinic Proceedings

• Massachusetts General Physicians Organization's Quality Incentive Program Produced Encouraging Results (2013) Health Affairs

• Balancing AMC’s Missions and Health Care Costs –Mission Impossible? (2013) New England Journal of Medicine

• The “Medical Neighborhood’ Integrating Primary and Specialty Care for Ambulatory Patients (2014)

JAMA

• Initial Results of a Cardiac E-Consult Pilot Program (2014) Journal of the American College of Cardiology

• Operational Lessons from a Large Accountable Care Organization (2014) Journal of Clinical Outcomes and

Management

http://www.partners.org/Innovation-And-Leadership/Population-Health-Management/About-PHM/Publications.aspx

http://www.partners.org/Innovation-And-Leadership/Population-Health-Management/About-PHM/Publications.aspx


• The largest integrated academic health care system in the United States

• In addition to two Academic Medical Centers, PHS includes:

• Community and specialty hospitals

• Managed care organization

• Community health centers

• Physician network

• Home health and long-term care services

Background on Partners HealthCare (PHS)

PHS by the Numbers •1.5M patients served annually

•6,500 physicians

•9,100 nurses

•64,000 employees

•$10.9B in revenue

• In 2012, we entered new contracts that put us at risk for medical expense trend

• PHS currently have over 500,000 lives in various accountable care relationships


The path we’re traveling at Partners

Pressure to reduce cost trend

New contracts with risk for trend

Internal PerformanceFramework (IPF)

Investment in Population Management Infrastructure

Changes to Partnersorganization structure

Primary Care Specialty Care

Care Continuum Patient Engagement

IS/Analytics

Improved quality and lower cost trend

Implement new local incentives/compensation

Network Composition

New relationships with community hospitals

and doctors


Over 500,000 lives in accountable care contracts(~60% of primary care patients; ~20% of system wide revenue)

Self Insured

Partners Plus

Commercial population, but savings accrue directly to Partners,

and improves our own lives

3

Covered lives: ~100k

Commercial

Alternative Quality Contract (AQC)

Younger population, specialists critical to

management

1


Medicare

Pioneer Accountable Care Organization

Elderly population, care management

central to trend management

4


Medicaid

Neighborhood Health Plan

Population with significant disability, mental health, and

substance abuse challenges

2

Covered lives: ~30k

12

Our contacts 4 years in…

Lives under the Accountable Care Model


Managing incentives in contracts that include risk for total medical expense (TME) trend

Risk/Shared Saving

Performance on TME for thedefined population

Performance on claims-based quality and safety metrics

System-wide Performance programs

Cost-standardized medicalexpense trend

EHR based quality and safety metrics

Compensation incentives

System wide infrastructure investments

Tax on clinicalrevenue

Local infrastructure investments

Risk/Shared Saving

13

Payers

Partners

Physicians and Hospitals


Payer 1

Payer 2

Payer 3

Payer 4

Payer 5

Payer 6

Partners

Internal

Performance

Framework

Adoption of

Tactical Programs

Lower the Cost

Standardized Trend

Improve Performance

on

Quality Metrics

Risk Adjusted Cost

Trend Benchmark

14

How the Internal Performance Framework (IPF) works

Strategic

Programs

Performance

Metrics

Local

Programs

Physician

Orgs.

•We determine the content,

not payers

•Renewed annually

•Shared goals, but

participants can choose

different paths

•Forfeited funds pay external

contract losses


2016 Internal Performance Framework (IPF)

Implementing PHS

Quality/Efficiency Strategies Reducing Medical Trend

Improving Select Quality

Measures

40% 40% 20%

Patient Centered Medical Home

• NCQA Recognition

iCMP (High Risk Care Mgmt)

• Process and outcome measures

• Innovation

Specialty Programs

• PCP/Specialty Collaborative Care

Agreements and E-Consults

• Specialty Programs (virtual visits,

PrOE, PROMs)

• Innovation

Hospital Metrics

• Medicare Spending per Beneficiary

• Nursing Process Measures

(pressure ulcers, falls with injury)

• Quality of Discharge Summary

Post-Acute Care Measures

• Readmissions

• Care Transitions

Trend Target (adult & pediatrics)

Big 3 Commercial: Cost

Standardized Medical

Expense (CSME)

Shared Risk: Hospitals and MDs

• Adult Diabetes Outcomes (3)

• Adult CVE and HTN Outcomes (2)

• Colorectal Surgery Protocols

• Menu of Process & Outcomes

Measures:

• Patient Experience (process &

outcomes)

• Infection Control Process

(CAUTI, CLABSI)

• CMS Measures (PSI 90,

NHQMs)

Adult MD Only

• Diabetes Screenings (3)

• Cancer Screenings (3)

• Depression Screening

• Patient Experience Composite

Pedi MD Only

• Asthma Composite

• Well Child Visits

• Patient Experience Composite

• Hospital Only

• Menu of Process & Outcomes

Measures (see above)


Primary Care Strategy

Problem• Primary care as currently organized has

limited capacity to meet both acute and chronic illness needs.

• The work requirements of primary care are unsustainable.

Approach• Provide additional resources and match staff

skills with required work.• Phased adoption using milestones and

NCQA recognition.• Align compensation with goals

Progress• 77% of practices achieving milestones (n=221)

• 38% of practices achieved certification• Improved performance on primary and

secondary prevention metrics• Improved provider satisfaction

Partners Practices PCMH Readiness and NCQA Status

The 10 Building Blocks of High-Performing Primary CareThomas Bodenheimer, M.DAnnals of Family Medicine

March/April 2014 vol. 12 no. 2 166-171

Readiness

•77% at readiness for NCQA L3•38% with NCQA L3


Integrated Care Management Program (iCMP)

Problem• Expenses are concentrated in a small % of

patients with multiple chronic conditions (9% of Medicare, 3% of Medicaid, 1% of commercial).

• Self-managing multiple chronic conditions challenging without assistance.

Approach• Identify high-risk patients and provide

care management and individualized care management plan.

• Demonstrated 7% cost reduction, reduced admissions, and 4% lowermortality

Progress• 13,972 high-risk patients actively

enrolled with a care plan (total iCMP patients)

• 84 care managers• 21 social workers • 6.6 pharmacists • 9 community resource specialists

• Lower rates of hospitalizations andED visits

Team

PMPM total medical expense lower after starting iCMP


Behavioral Health Integration

Problem• High prevalence rate of depression in primary

care (10%) with half of patients receiving treatment from their primary care provider.

• Behavioral health issues increase the cost for patients with chronic illness 3-5x.

Approach• Consultations for primary care physicians

with behavioral health specialists. • Care management for patients with

depression and anxiety offered within primary care setting.

• Training and decision aids to support primary care.

Progress• 68% of primary care patients seen from Oct to

Dec 2015 screened for depression (n=143,438)

• Over 5,800 consults averaging over 300 per month in 2015.

• 36 Collaborative Care practices with 1,650 patients enrolled

Collaborative Care Model

Patients

Primary Care Physicians

New Role: Mental HealthCare Coordinators

Psychiatrist and Social Workers

406 640914 1157 1292 1458

4061046

1960

3117

4409

5867

0

1000

2000

3000

4000

5000

6000

7000

Q4 2014 Q1 2015 Q2 2015 Q3 2015 Q4 2015 Q1 2016

Quarterly Consults

Quarterly Cumulative

Total : 5,687


Problem• Increase in demand for specialist services has

led to long wait times for appointments.

• 20% of referrals are for relatively simple questions that can be addressed by email.

Approach • Develop clinician to clinician consult

program in which referring physicians can obtain input from specialists directly and rapidly, without requiring a face-to-face visit.

• Participating MDs are paid for their time.

Progress• 35 active specialty practices (BWH, MGH,

TCMA)

• 5,983 e-Consults performed

• ~4,891 visits avoided (~$1.2M in savings)

e-Consult Request Form

Total e-Consults: 5,983

e-Consults


1) Relay Health Online Asynchronous Visits

In online learning envir onments, exchanges between students and teachers ar e frequently enacted asynchronously

rather than in simultaneous or face-to-face conversations. This type of communication taking place at dif ferent times

is a standard protocol for many online learning, auction, and business web services. W ith RelayHealth, a provider of

health-related web services, the Virtual Practice is testing a tool that conducts asynchr onous exchanges between phy -

sicians and patients to conduct online visits. V isits are available for about 100 non-ur gent symptoms and conditions

commonly seen in a primary car e practice. Patients login to the RelayHealth website and complete a r elevant online

interview using RelayHealth's web -

Visit®. The visit is conducted asyn -

chronously and allows patients to

request advice about non-urgent

symptoms and avoid unnecessary

office visits for minor pr oblems.

Using the RelayHealth e-visit plat -

form, patients participate in online

medical interviews that gather and

document key data about symp -

toms. Results of these online inter -

views are relayed to the physician.

A physician in the practice r eviews

the patient’s responses from the web

interview and determines a tr eat-

ment plan using communication

channels online. If the patient’s con -

dition requires further evaluation,

the physician will request that the

patient visit the office in person.

Currently, 357 patients have enrolled in the pilot study. Results of this pilot will be announced shortly .

2) Synchronous Communication | The Virtual Visit

We recently concluded two research studies which compared face-to-face visits with virtual visits using web cameras.

Though virtual visits ar e not meant to replace the traditional face to face visit in primary car e, virtual visits may be a

viable option in circumstances where patients need to be routinely monitored (i.e., in chronic conditions like diabetes,

hypertension, obesity or depr ession). Virtual visits may also be ef fective for triage of acute non-ur gent issues like up-

per respiratory infections or back pain.

In these studies5, a physician conducted visits with existing patients known to the physician's practice with comput -

ers equipped with web cameras and videoconfer encing software. We examined the feasibility, effectiveness and ac-

T h e Vi r t u a l P r a c t i c e | m g h v i r t u a l p r a c t i c e @ p a r t n e r s . o r g | Te l : 6 1 7 - 7 2 6 - 6 6 7 7 5

5 Dixon RF Stahl JE. Virtual Visits in a General Medicine Practice: A Pilot Study. Telemedicine and e-Health. August 1, 2008, 14(6): 525-530 .

RelayHealth | Sore Throat Interview

Problem• Increase in demand for in-person follow-up

visits results in long wait times and inconvenience (e.g. travel, time from work) and cost (e.g. parking, co-pays).

Approach • Develop two alternatives for in-person

follow-up visits for patients:

• Virtual Visits – real-time interactions between patients and providers using video.

• e-visits – web-based interactions using questionnaires to manage low acuity issues (i.e. cold, ear ache, etc) and chronic disease.

Progress• 395 clinicians conducted virtual visit/e-visit• 6,621 virtual visits performed • 11,664 e-visits performed

Virtual Visits

e-visits

•virtual visits: 6,621•e-visits: 11,664

Virtual Visit & e-visit Volume

Virtual Visits


Problem• Overuse of surgical procedures, which is

difficult to track and document, is costly and may not result in providing the highest quality of care to patients.

• Payer utilization process burdensome and ineffective.

Approach • Develop web-based decision support tool to

assess the appropriateness of surgical procedures.

• Improve decision-making process for patients and provide personalized consent form with risks/benefits.

• Reduce administrative burden associated with prior authorization.

Progress• 16 practices implemented PrOE• 9,391 PrOE assessments performed

*Recently completed, in process of launching to practices.

0%

20%

40%

60%

80%

100%

Percent Appropriate by Procedure

Appropriate May Be Appropriate Rarely Appropriate

PrOE Procedures

Cervical Spine* Lumbar Spine

Total Hip/Knee Replacement* Carotid Endarterectomy

Vena Cava Filter Placement Carotid Artery Stenting

Coronary Artery Bypass Graft Prophylactic Mastectomy*

Valve Replacement/Repair Mohs

Diagnostic Catheterization Weight Loss Surgery*

Percutaneous Coronary

InterventionIncisional Hernia Repair

ICD/CRT Implantation* Prostate Biopsy

Hysterectomy*

Procedure Decision Support


Patient Reported Outcome Measures (PROMs)

Problem• Traditional measures (readmissions,

infections) fail to measure value and improve symptoms, activities of daily living, and quality of life following an intervention.

Approach• Collect measurement of patient-reported

outcomes on mobile devices in clinics and from home.

• Use real-time trend data to inform patient care and aggregate data for decision-making, quality improvement, and demonstration of value.

Progress• 136,794 surveys collected• ~24 specialties, ~61 clinics across

Partners

Knee Replacement: Quality of Life

Knee Replaced

KO

OS

Qu

alit

y o

f L

ife

Sco

re(0

-100

, Hig

her

is B

ette

r)

Days Before/Since Surgery(From ~1y before to 1y after)

Total PROMS: 136,794

Total PHS PROMs CollectionMarch 2014- May 2016

361910051

19086

34703

52212

69850

93533

120094

136794

0

20000

40000

60000

80000

100000

120000

140000

160000

Jun-14 Sep-14 Dec-14 Mar-15 Jun-15 Sep-15 Dec-15 Mar-16


Care Continuum: alternatives to the ED and hospital

Problem Approach Progress

Partners Mobile Observation Unit (PMOU)

Unnecessary ED visits and admissions/readmissions are high cost and do not always provide patients with coordinated care in the right place at the right time.

Provide patients with care at home by a nurse

•158 patients admitted to program (84% of referred patients)•~15% bounce back rate for hospitalization or emergency department

Congestive Heart Failure (CHF) Telemonitoring

Heart failure patients have high readmission rates.

Provide CHF patients with home monitor to track and record symptoms

•714 patients enrolled in the program•20 new patients (on average) monitored each month

Post-acute Care Transition Programs

Unnecessary hospitalizations due to Medicare’s 3-day inpatient rule and high rates of readmissions from Skilled Nursing Facilities (SNFs).

•ACO permits waiver of the 3-day rule.

•Developed a network of 61 SNFs.

•296 waivers utilized•59% of ACO patients discharged to network SNF• 3% lower length of stay• 2% lower 30 day

readmission rate

Urgent Care Access to services is a barrier for patients and ED services are costly

Formed a joint venture with MedSpring to offer urgent care sites across MA

•First urgent care site open •Next two locations opening in late 2015


Patient Engagement Programs

Vidscrips, Shared Decision Making, and PCOI

Problem• Lack of easily accessible education materials and

decision aids, impacts patients’ ability to manage their care effectively and make informed decisions about their treatment.

Approach• Develop short, single-topic videos featuring a

patient's own healthcare provider.• Provide evidence-based decision aids (DAs) to help

inform patients making treatment decisions.• Develop a resource library of patient education

materials (Primary Care Office Insight).

Progress• 454 total vidscrips filmed by 361 participating

physicians. There have been 31,321 unique views.• 16,261 decision aids provided to patients with 880

providers trained to prescribe DAs. • 192,078 hits to Patient Education handouts.

Total : 31,321

Total :16,261

Total : 444,516


Analytics and IS Infrastructure

Problem• Disparate information and clinical data

systems impairs our ability to effectively redesign care delivery systems and measure our performance.

Approach• Single Electronic Health Record (EHR)• Enterprise data warehouse (EDW)

• hospital volume and margin• assessing variation in episodes of care• monitoring medical expenses and

utilization • monitoring quality metrics

Progress •eCare implemented at BWH, NWH, and MGH •693 EDW users

Total : 693

0

20

40

60

80

100

120

140

160

EDW Users by Quarter

New this Quarter Revoked


• Executive Dashboard

– Contract Performance

– Key Quality and Outcomes Indicators

– Implementation Goals (rolled up view)

• Management Dashboard

– Local Performance Comparisons

– Quality and Outcomes Comparisons

– Implementation Goals

• Local Practice Dashboards

– Care Gap Registries (prevention, CVD, DM, etc)

– Physician Utilization Variation

How are we measuring progress?


Population Health Management Index

• The Population Health Management Index (PHMI) calculates our progress in program implementation and healthcare cost savings.

• PHM programs “touched” 45,000 patients in 2014 and 105,000 patients in 2015.

• By the end of 2016, PHM is predicted to assist 258,000 patients with a cumulative total savings of $113 million.

• Annual savings in 2016 ($52 million) is the same amount as the PHM budget.

• Currently, PHM is predicted to generate $300+ million cumulative savings by end of 2018.

Estimated health care cost savings 2014-e2018


PHM implementation dashboard


3 Essential Trusting Relationships in HealthCare

38

Patient

Clinician

Management

Clinician

Management

Payer


Closing gaps in service delivery

Reach/engage

Find opportunities

for improvement

Intervention

Identification

Realized Improvement

Adapted from Eisenberg J. Transforming insurance coverage into quality healthcare:Voltage drops from potential to delivered quality.JAMA 2000;284:2100-07.

Potential Improvement

39


Rogers’ Law of Diffusion

Buy-in for change follows Rogers’ Law

Generating a Sense of Urgency and Commitment is about leveraging EarlyAdopters to engage the Early and Late Majority

Co

mm

itm

ent


Lessons Learned

1) Risk contracting imposes a much needed goal on providers for evaluating their services through a cost-benefit lens in addition to a volume lens

• Fee-based systems lack this perspective

• Budget-based systems lack this perspective

2) Risk contracts themselves cannot adequately adjust for the complexity services and/or differences in health status, therefore:

• Penalties must be limited

• Leadership should be accountable for

delivery system performance

• Physicians should be accountable for:

• Using the tools available to them

• Having excellent patient experience metrics

3) Not possible to write aspirations into a contract

4) Pace

41

Both systems operate in silos. Risk contracting on total cost of care provides incentives for silos to collaborate

Physician Tools for Managing Patient Care

Primary Care Specialty Care

• Care managers• Gap registries• E-consults• Behavioral Health• Mobile Obs Unit• Palliative Care

• E-consults• Appropriateness• PROMs• Variation data• Mobile Obs Unit• Palliative Care

Population Health Management at Partners HealthCare · 2016-10-11 · Population Health Management...

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