Trends In Care Delivery And Community Health

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Trends in Care Delivery and Community HealthState Public Health Leadership WebinarDeloitte Consulting LLPJune 20, 2013CDC Disclaimer: This webinar is provided as a public service. Inclusion of information in this webinar does not constitute an endorsementof the materials by the Centers for Disease Control and Prevention (CDC) or the federal government, and none should be inferred. CDC isnot responsible for the content of materials not generated by CDC.

AgendaWelcomePaula Staley, MPA, RNSenior Advisor, Office for State, Tribal, Local andTerritorial Support, Centers for Disease Control andPreventionOverview of Changes in HealthcareDeliveryMike Van Den Eynde, MBADirector, Deloitte Consulting LLPBob Williams, MDDirector, Deloitte Consulting LLPOverview of Minnesota ExperienceEllen Benavides, MHAAssistant Commissioner, Minnesota Department ofHealthOverview of Massachusetts Experience John Auerbach, MBADirector, Institute on Urban Health Research andPracticeQuestion & Answer SessionAll

Overview of Changes in Healthcare DeliveryMike Van Den Eynde, MBADirector, Deloitte Consulting LLPBob Williams. MDDirector, Deloitte Consulting LLP

Table of ContentsIntroductionMarket Changes: Fee-for-service to performance-based modelsCurrent state of Accountable Care Organizations (ACOs) and trendsCurrent state of Patient-Centered Medical Homes (PCMHs) and trends

Introduction

Chronic Disease Model for Systematic Care ManagementThe goal of the webinar is to create a foundation of understanding upon which to discuss the role of statehealth agencies in new care models.The Wagner Model of Chronic Care was developed by the MacColl Institute.-6-

-7-Trends in Care Delivery and Community Health.pptxCurrent stakeholders face fundamental challenges

Market Changes – The Need for Value Based Care

iFHP/Kaiser Comparative Price Report-9-Trends in Care Delivery and Community Health.pptxUS healthcare prices are multiples more than the rest of the industrialized world.

Looking at the current environment, the status quo is unsustainableProvider Revenue as a % of Cost (FY2010)1(Sample Market)Estimated Enrollment Growth 2011-201(Sample Market)Key TakeawaysEst. Future Margins based on Enrollment Growth1(Sample Market) Continued fee for service (FFS) rate reduction putspressure on cross subsidization Exchanges increase individual enrollment and consumerexpectations Shift towards segments with lower reimbursement (e.g.Medicare, Medicaid) Hospital margins may continue to decline, requiringcapture of premium dollar through broader structures,e.g., extended networks, accountable care Operational cost reduction may not be sufficient1Basedon sample client data and proprietary health reform model- 10 -

Market regulatory forces are driving alignment of physicians and hospitalsIn many cases, hospitals are providing a “safe harbor” to physicians buffeted by industry forces.Industry DriversImplications Pressure on operating margins due to increasing growthin the cost of clinical supplies, malpractice insurance,and labor.The industry drivers will lead to three main models ofphysician and hospital alignment in the post-Reformenvironment. Growth in the Medicaid and uninsured populations andhigher out-of-pocket costs for the insured is leading to arisk of decreased reimbursement.1. Physicians are an individual entity and contract toprovide health care services. This is likely in marketswhere:– An existing group is receiving outside capital. Increased emphasis on care coordination in order to takeadvantage of quality based economic incentives.– Private equity firms are entering into the market topurchase and consolidate physician practices. Limited capital availability due to the recession to makemajor capital investments for electronic health recordsand infrastructure.2. Physician practices and health systems combine assetsto form a new entity, similar to a foundation model. Thenew entity would be managed similar to a not-for-profit. Changes in Stark law regulations limiting traditionalphysician and hospital relationships.3. Hospital is the integrator and utilizes a variety ofstructures (e.g. physician employment, contractinginnovations) in order to align with physicians.- 11 -

Hospital-owned physician practices will continue to increaseSource: AHA Rapid Response Survey, Telling the Hospital Story Survey, March 2010.- 12 -

Durable “Strategic Destinations”The health system will need to develop a clear value proposition to create market differentiation. In thefuture, there are likely to be a limited number of paths toward sustainable margin creation.Profitability LeversCommon Strategic Destinations Being PursuedDeliver superior outcomes/service to realizesuperior reimbursement (The Innovator)Monetize assets/capabilities and extendconsumer relationships to achieve a greater‘share of wallet’ (The Diversifier)Use actual and virtual scale to drive asustainable unit cost advantage (TheAggregator)Integrate care across the continuum todecrease utilization and total cost (The HealthCare Manager)- 13 -

Strategic “On-Ramps” for taking on performance riskProvider organizations are pursuing different models to gain experience in risk assumption. These modelsare substantial transformation efforts as they evolve established ways of delivering care.- 14 -

Provider Marketplace TrendsAssessment of the provider marketplace demonstrates that market is growing even though providers areat different points in their readiness to take on value-based care (VBC).Haven’t StartedEvaluating OptionsTaking on RiskAlready TransformedDescriptionHave resisted change;May be due to limitedmarket demand, a lackof ability or resources tobegin, or uncertainty offutureBeginning to consideropportunities to preparefor VBC and taking smallfirst steps to initiatechangeHave taken initial stepsin taking on risk andhave a high level plan toshift towards VBCIntegrated deliverysystem that have beenfunctioning as an VBCtype entitySampleGeographiesSouth-EastTX, NE, CO, AZIL, MA, MI Rest of the marketExamples% of HospitalMarket Tucson MedicalCenter Banner HealthOrlando HealthSetonBaylor HealthCarillion25%50%20%Level of VBC ReadinessSource: Leavitt Group, Healthleaders Media Industry Survey 2012 .- 15 -SoCal, WA, Twin-Cities Dean HealthIntermountainGeisingerKaiser5%

Accountable Care Organizations (ACOs)

Accountable Care Solution Goals and HallmarksAccountable Care Solution GoalsDrive the transformation to a patient-centered care model that promotes access, coordinationacross the continuum, wellness and prevention by collaborating with physicians, starting withprimary care, in ways that allows them to successfully manage the health of their patients andthrive in a value-based reimbursement environmentHallmarks of Accountable Care SolutionSupport for high riskpatientsShared decisionmaking andaccountability withpatients and theircaregiversCoordination of careacross the deliverysystemFacilitated andensured accessPromotion ofwellness andpreventionOutcomes andcompliance withevidence-basedguidelines ismeasured andmonitoredThe hallmarks of patient-centered care solution align with how of ‘AccountableCare Organizations’ have been defined by the industry.- 17 -

Projecting Financial Impact of Performance RiskACO models offer a strong long-term value proposition.- 18 -

Number of ACO Entities1The number of entities is growing with every Centers for Medicare & Medicaid Services ACO release.1Basedon March 2013 data- 19 -

Total Number of ACO Entities by State/Territory1State/TerritoryACO Entities #State/TerritoryACO Entities #State/TerritoryACO Entities 5Arizona6Massachusetts18Puerto Rico2Arkansas3Michigan6Rhode Island2California22Minnesota6South Carolina3Colorado7Mississippi2South 2Vermont4Hawaii0New Hampshire8Virginia6Idaho1New Jersey10Washington1Illinois10New Mexico3Washington, DC2Indiana10New York12West Virginia0Iowa7North Carolina6Wisconsin7Kansas1North asedon March 2013 data- 20 -

Value Based Care (VBC) ModelsProviders continue to implement varying types of VBC models to drive clinical integration and performancerisk.Models for Providing Value Based CareMedicare MSSPModelPayer / ProviderPartnershipsEmployee ModelExpanded RiskModelsComprehensive/ GlobalDegree of Risk and Clinical IntegrationLowHighDescription of Models Low downside option Largely Fee forService model with alayer of Pay forPerformance Shared savings /bonuses for clinicalprocess drivenimprovements anddefined measures ofclinical metrics Many of the hospitalsare starting withProvider Employeemodels A single payer andmultiple providersdevelop relationshipthat carries partial risk Hospital employerstaking on risk withtheir own employees Requires realignmentwithin a limitedpopulation or caredelivery innovation(e.g. PCMH models) Low expected level ofrisk, due to controlledpopulation but typicalhigh utilization (1015%) Could begin withlimited risk and canexpand to limited gainsharing Existing provider riskbearing entities looking toexpand risk pool Better understanding andexpectation of actuarialand financial risk-takingneeded Expanded clinical andpopulation managementstrategies A comprehensiveand full risk modelfor a largepopulation Could includeparticipation ofmultiple payers andmultiple providers Includes IntegratedDelivery SystemMarket Examples 189 MSSP (Hospitals andPhysician Groups)Pioneer ACO’s Seton, SLHS Idaho, BannerHealth Cigna and 50 other CareCoordination GroupsScott and White HealthCareAetna / Optimus HC- 21 - Tucson Arizona Intermountain, Kaiser, DeanHealth System

Key Components of VBC StrategyVBC strategies typically have one or more components: cost leadership, utilization management, and/orrevenue diversification.Utilization Managementand Alternative CareDelivery ModelsPopulation Managementand RevenueDiversificationUnit Cost LeadershipUnit Cost LeadershipUtilization Management andAlternative Care DeliveryModelsPopulation Management andRevenue DiversificationUse scale and select partnershipsto lower the cost of service, whilemaintaining superior qualityUtilize integration to improvehealth, reduce need for care / useof expensive resources, andassume risk for delivering valuebased careLeverage brand, reputationand relationships to extendinto new products and services Top quartile performance in unitcost and quality Profitable at/close to Medicarereimbursement Expanding care continuum Implementing new programs toimprove costs and revenueperformance Revenue base shifting towardsglobal/fixed payments over time Developing relationships withnew customers/segments- 22 -

VBC CapabilitiesSuccessful VBC models will require strong capabilities in six critical areas.Leadership and GovernanceInformation and Integration Services Governance system of accountability Physician leadership decision-making rights andresponsibilities Performance measures to inform clinical and businessdecisions Communications and change management approach Clinical informationsystems Data warehouses Analytics and businessintelligence Interoperability and datasharingClinical Integration Population healthreporting Secured healthinformationNetwork and Physician Alignment Care coordination and transition processes Clinical protocols and guidelines Tools/processes to support integration and carecoordination Quality, safety, and outcomes Population health management/ care management/disease management (vs. case management) Patient engagement/satisfaction High value network composition Physician alignment Community/public health programs and servicesengagement Provider evaluation and performance metrics Quality and performance reportingBusiness OperationsIncentive Alignment Process standardization Resource management Economic model Service operations Cost management Customer relationships Marketing and sales Value-based riskarrangements Rating and underwriting Legal and compliance Distribution model Performance improvement Revenue cycle- 23 - Compensation andincentives Third-party agreements

Conceptual IT ArchitectureHealth care is focused on acquiring clinical data and facilitating provider care management workflow.1. Connectivity, Security and Interoperability: Connects to all thedata producers, provides access to data consumers, andvalidates access rights.2. Data Aggregation and Hosting: Retrieve data from the dataproducers and transform it to fit the meta-data storingstructure.3. Data Analytics and Content: Using self-actualizing trends andbusiness solution-specific heuristics, analyzes transactionaldata, and creates enriched information. Data delivery occursvia screen-reports and services/API.- 24 -4. Core Applications and Workflow/Automation:Orchestrates the execution of activities that constitutesthe care continuum, gathering contextual informationfrom both the transactional systems as well as the datawarehouse.5. Engagement: Key interfaces for both patients andphysicians to facilitate their interactions with the VBCsystem, leveraging workflow and analytics to enhanceengagement and satisfaction for both thesestakeholders.

Key Solution Components that Drive a Shift to Accountable rmationMemberActivationTechnology InfrastructurePayment Innovation Moving from volume to value-based payment modelsCare Management Promoting ensured access and proactive longitudinal population health care built around the needs of thepatientMember Activation Engaging attributed members as active participants in the model and encouraging the establishment of arelationship with a trusted providerTechnology Infrastructure Creating the information and work flow tools that will enable the transformation for all constituents across thecontinuum- 25 -Trends in Care Delivery and Community Health.pptxProvider Transformation Giving providers the information, tools, and resources they need to move towards a proactive, coordinated,population health model

Patient-Centered Medical Homes

What exactly is a Patient-Centered Medical Home (PCMH)?Source: iew.html- 27 -Trends in Care Delivery and Community Health.pptxA patient-centered medical home integrates patients as activeparticipants in their own health and well-being. Patients are cared forby a physician who leads the medical team that coordinates allaspects of preventive, acute and chronic needs of patients using thebest available evidence and appropriate technology. Theserelationships offer patients comfort, convenience, and optimal healththroughout their lifetimes.

PCMH ModelA PCMH requires a comprehensive approach.Patient Provider RelationshipsPatient Registry Patient-related tools (education and awareness)developed and distributed Trained staff Signed agreement or documented patientcommunication to establish relationship Systematic notification to patients about partnerships Paper or electronic Clinical Information – manage all established patients inpractice unit classified by disease, regardless ofinsurance coverage Incorporates evidence-based care guidelines Available and in use at point of care (data from EMR) Used to flag gaps in carePerformance ReportingIndividual Care Management Allows tracking and comparison of results at a specificpoint in time across the population for a specificdisease Systematic, routine, aggregate-level reports withcurrent, clinically meaningful data on patients in registry Actively analyzed in provider self-assessment Population-level, practice unit and provider-levelreports Validated and reconciled for accuracy Trend reports to manage changes over time- 28 - Practice unit leaders and staff have beentrained/educated on PCMH concepts Team of multidisciplinary providers Several nonphysician members, including RN Evidence-based care guidelines in place Strategic action plan and goal setting for all patientswith a chronic condition

PCMH Model – Additional InformationLinkage to Community ServiceExtended Access Provider office conducts comprehensive review ofcommunity resources for population that they serve Community resource database Established collaborative relationships with communitybased organizations Practice unit team trained on available resources foraccurate referralsPreventive ServicesPrimary Prevention Program Identify and educate patients about personal health behaviors to reduce risk of injury and disease Systematic approach to provide preventive care and services according to preventive care guidelines Strategies to promote and conduct outreach regarding ongoing well-care visits and screenings Reminder system in place for preventive care screenings Incorporate patient’s outside health encounters into patient record Written standing order protocols allowing practice unit care team members to authorize and deliver preventiveservices according to physician-approved protocol without examination by a clinician- 29 -

PCMH Model – Additional Information (cont.)Self Management SupportSystematic approach to empowering the patient with chronic illness Clinical team familiar with and trained on self-management concepts and techniques Offered to all patients with the chronic condition selected for initial focus (based on need, suitability, andpatient interest) Follow up for chronic care patients engaged in self-management support Regular patient experience surveysPatient Web PortalCoordination of CareSpecialist Referral Facilitates two-way communicationbetween patient and provider Patients can request and scheduleappointments E-visits for patients Provider notification for patientadmit, discharge or other services Process for exchanging medicalrecords and discussing care withother providers Separate guidelines for PCP officesand specialist offices Guidelines for timeframes forappointments and informationexchange Patients able to log self-administeredtests and view results of providergiven tests Alerts to providers regardingpotential health issue based on selfreported patient data Track care coordination activities forpatients with chronic conditions Flag patient issues requiringimmediate attention Transition plans between caregivers Directory of routinely referredspecialists Practice unit makes specialistappointment on behalf of patient Electronic tools to avoid duplicationof testing and prescribing- 30 -

PCPCC Payment ModelA blended payment model will be determined by the quality of care provided and how physiciansand practices meet performance standards- 31 -

Reported OutcomesPreliminary research has demonstrated the quality of care and cost improvements resulting from PCMHprograms.PCMH Site and OutcomeGroup Health Cooperative of Puget Sound 29% reduction in ER visits 16% reduction in hospital admissions Reduced costsGeisinger Health System 18% decrease in hospital admissions Improvements in diabetes and heart disease care 7% reduction in costsVeterans Health Administration Improved Chronic Disease treatments 27% reduction in ER visits & hospitalizations Lower median costs for veterans with chronic conditionsHealth Partners Medical Group MN 39% decrease in ER visits 24% decrease in hospital admissions Enrollment cost reduced to 92% of the state averageIntermountain Healthcare Medical Group CareManagement Plus 39% decrease in emergency room admissions 24% decrease in hospital admissions Net reduction cost of 640 pp and 1,650 for high risk patientsBlue Cross Blue Shield of SC – PalmettoPrimary Care Physician 12.4% decrease in ER visits 10% decrease in hospital admissions Total medical and pharmacy costs were 6.5% lowerMedicaid Sponsored PCMH Initaitives NC: 974.5m savings over 6 yrs & 16% lower ER visits CO: PCMH Children's annual median cost was 2,275compared to those not enrolled 3,404Miscellaneous PCMH Programs John Hopkins: 24% reduction in total Inpatient days Genesee MI:50% reduction in ER visits Erie County: Organizational savings of 1m/1000 enrolleesSource: PCPCC Pilot Guide, 2010.- 32 -

Medicare PCMH Medical Cost PerformanceProvider-based contracts managed inpatient (and readmissions) more effectively and was the mainsource of savings even as OP and professional costs rose slightly.The performance gap represented over 200M in medical costs for the populationmanaged.- 33 -Trends in Care Delivery and Community Health.pptxComparison of PCMH Medical Cost Components Medicare Advantage Program

Physician Group Performance to Best Practice Model- 34 -Trends in Care Delivery and Community Health.pptxThe infrastructure that supports the provider model has a strong (but not exact) correlation and financialperformance.

Overview of Minnesota ExperienceEllen Benavides, MHAAssistant Commissioner, Minnesota Department of Health

Overview of Massachusetts ExperienceJohn Auerbach, MBADirector, Institute on Urban Health Research and Practice

Questions

Copyright 2012 Deloitte Development LLC. All rights reserved.

Trends in Care Delivery and Community Health State Public Health Leadership Webinar Deloitte Consulting LLP June 20, 2013. . Current state of Accountable Care Organizations (ACOs) and trends. Current state of Patient-Centered Medical Homes (PCMHs) and trends. Introduction.File Size: 2MBPage Count: 38Explore further2020 Healthcare Trends and How to Preparewww.healthcatalyst.comFive Health Care Trends For 2020 Health Affairswww.healthaffairs.orgTop 10 Emerging Trends in Health Care for 2021: The New .trustees.aha.orgRecommended to you b

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