What we’re facing…

Division of Population Health Management

Partners Approach to Meeting the Healthcare Cost Challenge

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

Nuffield Trust Health Policy Summit 2014March 6, 2014


What we’re facing… Constraining the growth of healthcare costs is a national priority

Involvement of physicians through changed incentives is unavoidable

PPACA - the imperative will persist even if the specifics change

The market is using a similar play book – closed networks, budget-based risk, cost sharing, restriction of choice – and this may generate the same backlash as 1990s managed care era

But... The economy is much worse Government is proactive (3.6%) 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

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Implications for providers

Our focus should be on reducing medical expense trend to as close to the rate of general inflation as we can We want to be part of the solution

This means taking financial risk for costs of care Shared savings (Pioneer ACO), bundled payments, global payments

Partners increased ability to care for populations of patients Successful CMS Demo, increasing evidence for other tactics Universally adopted EHR

Challenges1. We need tactics that will be successful under any new payment model

2. How to make external incentives meaningful to our physicians

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 worsening

the regulatory environment3


What is an ACO?

An organization that agrees to share the financial risk for the care of a defined population

Shared financial risk = rewarding providers for reducing medical spending by giving them a share of the net cost savings; may also include financial penalties for cost increasing above benchmark

Defined population = every primary care patient whose insurer has signed a risk contract with that provider, regardless of where they receive care

Source: Leavitt Partners Center for Accountable Care Intelligence at http://healthaffairs.org/blog/2014/01/29/accountable-care-growth-in-2014-a-look-ahead/

Total Accountable Care Organizations by Sponsoring Entity

Total = 606

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Evolution of ACOs

Estimated Accountable Care Lives in Public and Private ACOs*

Accountable Care Organizations by State*

18.2m covered lives compared to 13.6m at end of 2012

•More than half of the US population (52%) live in primary care service areas served by ACOs, approximately 28% live in areas served by 2 or more ACOs.**

•Los Angeles, Boston, and Orlando, have the most ACOs in the nation.* In Boston, ACOs care for more than 60% of patients.***

*Leavitt Partners Center for Accountable Care Intelligence at http://healthaffairs.org/blog/2014/01/29/accountable-care-growth-in-2014-a-look-ahead/**http://www.oliverwyman.com/media/ACO_press_release(2).pdf***http://www.acpinternist.org/archives/2013/07/acos.htm

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Background on Partners HealthCare

Partners HealthCare (Partners) Integrated delivery system in Boston MA, includes two

AMCs Massachusetts Hospital (MGH) Brigham Women’s Hospital (BWH)

Partners became a Pioneer ACO, January 2012 Includes community and specialty hospitals, a physician

network, home health and long-term care services, and other health-related entities

615 PCPs 76,000 patients

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Enhanced access to specialty services

The path we’re traveling at Partners

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Pressure to reduce cost trend

New contracts with risk for trend

Internal PerformanceFramework

Investment in Population Management Infrastructure

Changes to Partners org structure

Partners in Care (PCMH & care coordination for high risk patients)

Sustained cost trends near GDP

Implement new local incentives/compensation

Network Affiliations

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2

3 New relationships with community hospitals and doctors

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Our new contracts…almost 2 years inLives under the Accountable Care Model

Medicare Commercial

Pioneer Accountable Care Organization

Elderly population, care management

central to trend management

Alternative Quality Contract (AQC)

Younger population, specialists critical to

management

21

Medicaid

NHP

Population with significant disability,

mental health, and substance abuse

challenges

3

Self Insured

Partners Plus

Commercial population, but savings accrue

directly to Partners, and improves our

own lives

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Covered lives: ~80kCovered lives: ~80kCovered lives: ~25KCovered lives: ~25KCovered lives: ~350KCovered lives: ~350KCovered lives: ~75kCovered lives: ~75k

Partners currently manages roughly 500,000 lives in various accountable care relationships

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Priority programs

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Priority Population Health Management ProgramsPrimary Care •Patient Centered Medical Home (PCMH), including especially

access•High risk care management•Mental health

Specialty Care •Referral management•Virtual visits•PrOE/PROMs•Bundles

Care Continuum •SNF networks•Mobile observation units •Urgent care

Patient Engagement •Shared decision making•Virtual patient communities•Customized risk and educational materials

Infrastructure •IS, analytics •Program management


Virtual visits and technology tools

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Email

Video Conferencing

Telephone

Text Messaging

Electronic Curbside

Technology Pediatric Virtual Video Pilots •Follow up visits in the home for children and adolescents with Autism, ADHD, Substance Abuse, etc,

•Post-acute burn consults for patients at Boston-Spaulding Rehabilitation Hospital

•Parents of patients in the PICU virtually attend rounds with care team and their child

Cardiology Curbside Consults*

*Start of pilot Jan 2014

•Referring physicians can quickly contact a cardiologist in the outpatient setting and receive recommendations in the electronic medical record

•Offers referring providers and patients an alternative to waiting for in-person cardiology appointments


Chen, A. H., Kushel, M. B., Grumbach, K., & Yee, H.F. (2010). Practice profile:.A safety-net system gains efficiencies through ‘eReferrals’ to specialists. Health Affairs (Millwood), 29(5), 969-71.

Why is this important? Assessing the appropriateness of referrals prior to scheduling may have

a positive impact on our efforts to Reduce avoidable office visits Increase access for our sickest patients Increase experience coordination and efficiency of specialist visits

through pre-visit planning

Approaches for managing referrals

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Idealized patient journey through an episode of care that includes a procedure

Patient Problem

Assess Appropriateness

CriteriaAssess

Risk

Schedule OR

Procedure Recovery Physician encounter

Possible Need for

Procedure

Shared Decision Making

Pre-Procedure

Testing

Tier 1, 2 Outcome Measures

Tier 3Outcome Measures

Personalized Consent Form

Informed Consent

Tier Category Examples

1 Health status achieved Survival and degree of health recovery

2 Process of recovery Time to recovery and return to normal activities

3 Sustainability of health Sustained recovery and recurrences, including long term consequences of therapy

Outcome measures hierarchy:Outcome measures hierarchy:

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Appropriateness Data Repository

Procedure Scheduling

PrOE Appropriateness tool

Public Reporting

PCI, CABG, Vascular,

Harris Joint

Internal Performance Dashboards

Billing and Prior Authorization

RPM, RPDR, CDR, EMPI

Pre-populated data fields (NLP search)

INPUTS OUTPUTS

Personalized consent form

Existing registries

LMR, OnCall

Data storage

EMR

Appropriateness Indications & Decision support

Measurement & analysis of appropriateness and

outcomes inform guidelines and indications in real-time

Measurement & analysis of appropriateness and

outcomes inform guidelines and indications in real-time

Data passback to registries (Web service)

Copy of appropriateness results placed in LMR and CDR

EHR note created

PrOE: Inputs and outputs

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Percent of Procedures with a PrOE Assessment

Appropriateness Scores for Diagnostic Catheterization by Month

2014 Procedures•Incisional Hernia•Prostate Biopsy •Gastric Bypass•Valve Repair•Lumbar Fusion •Peripheral Vascular Disease Therapies

**Hannan, EL, et al. Appropriateness of Diagnostic Catheterization for Suspected Coronary Artery Disease in New York State. CIRC INTERVENTIONS. January 28, 2014. 113.000741n=745

n=8986

Median hospital-level inappropriateness rate is 28.5%**

Appropriateness Scores for Diagnostic Catheterization at MGH vs. NY Cardiac Database **

Results to date

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Patient Reported Outcome Measures (PROMs)

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Outcomes that matter to patients: direct collection of information from patients regarding symptoms, functional status, and mental health.

Why PROMs? Improves care of individual patients through better

monitoring and improved responsiveness Improves system-wide care by measuring/improving the right

outcomes – those that matter most to patients

How are PROMs collected? Patients enter information into an electronic platform using

iPads, patient portal, or the web

PROMs will be implemented for all sites and diagnoses

Current Conditions include: Coronary Artery Disease: CABG, Cardiac Catheterization Osteoarthritis Valvular Disease Diabetes Depression Additional conditions planned for 2014


What does PHM cost?

Total CostPHM Programs

(Annual Operating & 1x

expense)

PHM Cost as a Percentage of External Risk TME(At 2017 Steady State Run Rate)

PHM Program Costs as a Percentage of External Risk TME only

Total Costs as Percentage of External Risk TME only

4.96%

4.96%

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What is the ROI?

$0

$50

$100

$150

$200

$250

2015 2016 2017

Total PHM Acceleration Cost

Savings from External Risk

Savings from full IPFSavings from full panel (Loyalty Cohort)

PHM Program Savings Relative to Total Operating Program Costs

(Assumes Steady State in 2017)

•Two-thirds of PHM acceleration costs fund programs that generate TME savings

•Remaining funds support infrastructure, innovative pilots (i.e. SNFist), community specialist engagement that accrue minimal or difficult-to-measure savings

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Key Challenges Overlapping programs and contracts (e.g. Chronic Disease Demo)

Timely data and useful performance measures (CMS delays with delivery of prospective patient information)

Transition costs—establishing the EHR infrastructure Funding the infrastructure (no grant funds)

Intersection between the multiple Boston area ACOs Notification management

ED notification Discharge notification

Sharing of best practices between colleagues

Learning what works and providing timely feedback for policy changes/enforcements to CMS

Limited leverage when patients seek covered services that provide little or no benefit

Time to ROI not consistent with duration of contracts

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What we’re facing…

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