Transforming Medical Groups To Value Based Care

Eric Herman, MDMedical Director of Population HealthMultiCare Health System, Tacoma, WA

Overview

• Setting The Stage•MultiCare’s Journey in VB Care• Shared Learning• Checklist of Critical Success Factors• Questions

BACKGROUND

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MultiCare – Tacoma / South Seattle

Who we we?

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• Non-Profit• 10,622 employees; 2,000-member medical staff• 4 Adult Hospitals & 1 Pediatric Hospital• 26 Primary Care Clinics; > 100 Clinics • 3 PCMH Sites; All 25 sites by 2016• Four-county clinic network • RediClinics / Virtual Medicine• Home Health & Hospice• Behavioral Health• Occupational Med

MultiCare Health Systems

Flashback

Flashback to 1955

“The fast food restaurant is convenient for a quick meal, but I seriously doubt it will ever catch on.”

Healthcare1955

Flashback to 1955

“No one can afford to be sick anymore, at $15.00 a day in the hospital,

it's too rich for my blood.”

Another Example

Flashback to 1955

“Can you believe some folks think that one day, physicians will be paid not only on the quality of medicine they practice,

but on how well they communicate, and on the patients’ perception of how they were treated?”

Pay the bill

Yet Trouble Loomed In The Years Ahead

• Staggering increases in health care costs• Disparity in Health Care Demographics• Access to the Health System• Quality of Care

• Declining interest in primary care

Were there other warning signs for transformation?

2003 - Warning Signs for Care Model Transformation

• Primary Care: Is There Enough Time for Prevention?Am J Public Health. 2003 April; 93(4): 635–641.

In all, an annual total of 1773 hours, or 7.4 hours of every working day, is required for the provision of all recommended preventive services to a practice of 2500 patients with age and sex distributions based on the US population.

2009 - Warning Signs for Population Health

A Basic Summary of America’s Financial StatementsFeb. 2011, USA Inc.

And Yet The System Stumbled On…

So Why All The Interest Now?

A Basic Summary of America’s Financial StatementsFeb. 2011, USA Inc.

So Why All The Interest Now?

Every U.S. family of 4 is paying the dollar equivalent of a new Chevy Cruze in healthcare costs. Every year. Without financing.

2012 Milliman Medical Index

Not Surprisingly, the Art of Medicine has Changed

• Value Based Care for entire populations• Care being dictated by health care entities, not MDs• New systems and stakeholders of care delivery• Virtual Medicine• Increasing Workloads and Accountabilities• Challenging cultural expectations & patient satisfaction

Gold in cost redux

Who Wants A Piece of the Transformation Pie?

• CMS• Health Systems• Insurers & TPAs• Employers• Big Pharma• Commercial Enterprises• Your Organization

No easy task

17“I have an enormous

favor to ask you”

The Dog Days of Health Care?

Your Organization You

Old dog new tricks

The New Landscape of Population HealthIt’s actually not so bad

• Growing % of revenue is based on performance

• Payors ‘triaging’ patients to high performing systems• Complete transparency of medical groups and providers

• Strategic delivery of the right care to defined populations• Transition from Hospital -> Ambulatory• Greater care management across the system• Expanding Care Team partnerships: behavioral health, pharm, etc.• Movement towards patient empowerment /engagement

• Expanding ACO / CIN Networks

• End game = achieving successful risk based care• Maturing into a competitive delivery system without gainshare incentives

Success in the Age of Population HealthA few basic principles

• Not about how much you did• It’s about how well you do & are perceived

• Decreased ED & Hospitalizations• Achieving National Quality Targets & high patient satisfaction• Improving Risk Adjusted Coding

• Incentives for good performance• Penalties for poor performance• Gainshare for decreasing total cost of care

MULTICARE’S JOURNEY INTO VB CAREAN INTROSPECTIVE CURIOSITY

What we stood up

Acceleration of Value Based Care

2012 2013 2014 20150

10,000

20,000

30,000

40,000

50,000

60,000

70,000

Growth in Value Based Patient Population

Medicaid Medicare Commercial Total

Axis Title

Assigned or At-tributed Patients

Over 50% of our patients are now within VB Care

Overview of Value Based Care at MultiCare

• 2012 – Residency program – 1 payor – 2500 pts

• Currently >70,000 patients – 14 payor plans (MA, Commercial, ACO)• Mostly upside contracts – Gainshare based on reduction of

TCOC/MLR and gatekeeper quality metrics, • PMPM stipends for care coordination• Robust analytics platform with real-time gaps in care, parallel Epic’s

development (Healthy Planet), HIE, and clinician transparency• Established governance for population health workflows• Extensive program of care coordinators, managers, and navigators• ACO partnerships and Clinically Integrated Networks

Day in the Life of VB Care – Low Risk Patient

• Outreach Message (system)• Receives letter or EMR message of outstanding gaps in care for

DM, Breast CA screening, Annual Wellness Visit• Messages are carefully scripted and patient centered

• Outreach Telephone Calls (care coordinator)• Receives a related phone call from an MA representing their PCP• Reviews gaps in care with patient and discusses next steps• Places orders per protocol, schedules f/u appt (e.g. AWV)• Supports identified barriers such as transportation needs

• On-Line Patient Portal (patient)• Reviews gaps in care, forwarded education materials, messages, upcoming appts• EMR messages their doc a about other labs they want such as an overdue TSH

• Annual Wellness Visit (RN, MD, patient)• RN stages the screening and medical history review for PCP• PCP reviews staged content, labs, performs routine care and exam• RN wraps up encounter and completes forms

• 3 months later (cc, patient)• Patient gets follow up reminder call that mammogram is still pending• Patient completes study, results sent that day by patient portal

Day in the Life of VB Care – IP High Risk (Q2)

• During Admission (RN, SW, patient)• Patient has extensive health assessment completed• Patient meets with Personal Health Partners (PHP), reviews plan of care

HA, d/c planning, addresses barriers, ensures all connections are in place• After D/C (PHP, patient)• Pt receives f/u phone call/home visit from PHP, reviews POC, Rx, ensures all

POC elements are in place, support for barriers, ensures f/u with PCP • PCP follow up visit (PCP, PHP, patient)• PHP proactively reviews essential POC issues relevant to PCP prior to visit• PHP meets with patient during encounter and PCP as needed• PCP provides routine & coordinated care

• After PCP visit (PHP, patient)• PHP reviews chart, confirms progress with POC• PHP coordinates patient & the care team per role, updates chart

Day in the Life of VB Care – PCP Lens7:30 Reviews schedule: Gaps of care, coordination issues

7:45 Discusses patients: 1:1 with care team including future PHPs

7:55 Attends Clinic Huddle: Highlights important issues, hears about system updates

8-12:30 Morning Clinic: Patients Q 15 minutes; charting, in-baskets, faxes, phone calls, personal matters

12:30 Reviews Analytics: Analyzes trends, potential incentive / benefits, reviews gaps in care

12:45 Clinical Staff Meeting: Discuss relevant operational issues, new partnerships, CME

1:30 – 5 Afternoon Clinic: Patients Q 10-20 minutes, charting, in-baskets, faxes, phone calls, personal matters

5:00 Reviews Analytics: Sends Dr. Herman an email requesting “clarification”throughout the year, track trends, progress, realization of incentives

Day in the Life of VB Care – Admin. Lens6:00 Validate analytics measures for Colon CA screening

6:30 Review payor data for Q1 performance, gaps in care, trends

7:00 Clinician Governance of PHP Workflows

• Discuss comprehensive support strategy for DM poor control and Breast CA screening

• Includes clinicians, operations, nursing, educators, IT, analytics

8:00 Meet with Care Coordinators, discuss challenges in outreach

9:00 Meet with payor – Review all data, discuss barriers, strategies, next steps

10:00 Review EMR platform for VB Care, ensure alignment with HEDIS, prior analytics

11:00 Discussion of strategic expansion of RN pilot to support AWVs and HCC code capture

12:00 LUNCH – Are you kidding?? Review countless emails and clinical in-basket messages

1:00 Discuss VB Care / Pop Health strategies for employee health plan

2:00 Discuss new CMS offering for management of chronic conditions

3:00 Review strategy for Virtual Health

6:00 Medical Staff Committee: Provide updates, pose quality related questions…Eye Candy

of Analytics

Provider Performance Dashboard (PPD) – Provider Overview

PPD Provider Performance– Diabetes Poor Control

PPD Gaps in Care Listings – DM Poor Control

PPD Provider Comparison– DM Poor Control

Provider Performance Dashboard – Population View

Metrics Portfolio – Clinical Measures

Metrics Portfolio – Payor Measures

Metrics Portfolio – Prioritized Measures

Advanced Access Dashboard

CHF Dashboard

SHARED LEARNING / CORE COMPETENCIES

Payor Alignment (Part One)

• Management of complex contractual requirements that determine incentives, penalties, and metrics• Management of payor sponsored services against internal

offerings• PCP panel reconciliation• Contractual requirements for timely change

management • Internal governance for PCP changes / discrepancies

• Collaborative prioritization of high priority next steps• Proactive staging for valued added work in Q1

Payor Alignment (Part Two)

• Acceptance of your VB book of business measures• Resisting the urge to over promise on all incentives• Management of Meetings• Avoid overloaded schedules• Transparent action items and minutes• Proactive review of meeting documents, data and agendas• Consistent internal location for all shared documents• Be good partners, but don’t get bullied

Population Health Alignment (Internal)

• Strategic prioritization of population health efforts towards:• ROI Strategy: Utilization, quality, MRA, Employee Health programs• Risk stratification• Best in class performance of quality measures against uncertain

performance in new incentive programs• Development of Risk Adjustment programs and culture• Incentivizing good clinician performance

• Prompt development of care team & care model• Access to care is absolute• Well-considered oversight for PH workflows and resources• Capacity to respond to the dynamic priorities

Expanding the Care Team

• Absolutely Essential• Too much work for the PCP team• Requires continuous changes in culture, quick wins &

demonstrated value, seamless integration and transparency

• Key Areas of Expansion• Care Navigators, Managers, Coordinators, Coaches• Behavioral Health• Pharmacy• Bringing back RNs in clinic settings• Specialist Integration within PCP workflows

Cultural Alignment for All Stakeholders• What, How (Who, When), Why• Value proposition for all stakeholders• Goals (visionary) & objectives (measurable)

• DNA of transformation• Triple Aim (Quality, Cost, Experience)• Cultivate innovation and Lean workflows• Promote transparency

• Essential Partnerships: Executives, operations, clinicians, clinical back office staff, support staff, insurers, patients, care management, IT, coding, payor contracting, business and strategy, project management, pharmacy, behavioral health, etc.

Analytics• Seamlessly integrated actionable data aligned with EMR• Independence from 3rd party data whenever possible• Poor data integrity and challenging delays• Internal competencies for complex build of metrics • Strategy for claims data integration

• Proactive design of required metrics• “Slice and dice” data to identify clear targets for clinical process

improvement

• Strategy for clinician validation• Change management capacities for enhancements

Communication Strategy

• Intra-organizational• Knowledge of value propositions, departmental cultures, syntax• Communicate with high specificity and sensitivity

• Clinical stakeholders• Drive home the triple aim of value based purchasing• May require multiple modalities but be certain to avoid fatigue• In-person peer to peer dialogue

• Inter-organizational• Clearly stated point(s) of contacts for data & communications

Patient Engagement

• Avoidance of redundant outreach, services, assessments• Validation of population health workflows and scripting• Validation of central vs. local workflow preferences• Consistency of all workflows across the continuum• Including care management and behavioral health

• Consider 3rd party crowd sourcing products

Exploring Non-Traditional Modalities

• Virtual Medicine• Virtual office visits and follow up coordination• Virtual after hours care

• New CMS or commercial offerings• Piloting new care models, workflows• High Risk Clinics, Employee wellness programs, etc.

• Patient entered data• Integrated devices (BP cuffs, fit bits)

Putting it all together

CHECK LIST FOR VALUE BASED PURCHASING

Checklist for Value Based PurchasingCategorical considerations of our critical success factors that may serve your organization vi to the 80/20 rule. Many other lists are widely available.

Alignment: Cultural & Operational; Value Proposition Business Integration & ROI validation Multidisciplinary Care Team & Care Model Access to care: Capacity, Scheduling workflows Analytics: Utilization, Quality measures, Operational Performance, ROI Information Technology Integration: (EMR / Clinical Systems) Care Pathways & Best Practices Physical Resources (office / workstations) Clinical & Operational Champions Project Management: Operational Alignment, readiness, implementation, etc. Coding & Compliance Community Partnerships Risk Stratification Strategy Prioritization Strategy Governance Strategy Insurer/Payor Coordination Strategy Patient Advocacy Strategy Implementation Strategy Change Management Strategy Education Strategy Communication Strategy Process Improvement Methodology

Checklist for Value Based PurchasingCategorical considerations of our critical success factors that may serve your organization according to the 80/20 rule. Many other lists are widely available.

Alignment: Cultural & Operational; Value Proposition Business Integration & ROI validation Multidisciplinary Care Team & Care Model Access to care: Capacity, Scheduling workflows Analytics: Utilization, Quality measures, Operational Performance, ROI Information Technology Integration: (EMR / Clinical Systems) Care Pathways & Best Practices Physical Resources (office / workstations) Clinical & Operational Champions Project Management: Operational Alignment, readiness, implementation, etc. Coding & Compliance Community Partnerships Risk Stratification Strategy Prioritization Strategy Governance Strategy Insurer/Payor Coordination Strategy Patient Advocacy Strategy Implementation Strategy Change Management Strategy Education Strategy Communication Strategy Process Improvement Methodology

SUMMARY

“I don’t care if she is a tape dispenser.I still love her.”

Considerations for Next Steps

• Determine your interest and capacities for VB Care• Consider the full scope of the effort, capacities, readiness,

and core competencies that exist or need development• Meet with executive stakeholders to understand how the

organization’s business strategies align with VB care• Align your interests with that vision• Ensure your efforts can measurably benefit the goals and

objectives of your organization’s VB Care strategy• Remember the end goal • A robust, competitive VB Care product, that sets the stage for

risk based contracts with a host of partnerships

Conclusions

• VB Care is here to stay.• At present, many upside opportunities. Penalties are

coming. The goal will be engaging in risk based contracts.• High priority efforts typically focus on • Decreasing hospital & ED utilization• Achieving best in class performance with quality measures• Improving Medicare risk adjusted coding.

• There are many moving parts• Align, Align, Align• Confirm capacities, resources, and project management support

• In the end, VB Care is good for patients and is distinctly rewarding.

Questions?

Please feel free to contact me anytime by email:Eric.Herman@multicare.org