considerations: transformation to a population health system stephanie berkson, mpa vice president...

CONSIDERATIONS:CONSIDERATIONS:TRANSFORMATION TO A TRANSFORMATION TO A

POPULATION HEALTH SYSTEMPOPULATION HEALTH SYSTEMStephanie Berkson, MPA

Vice President Population Health

UW Health

September 18, 2015

“Population Health

Management IS our

Strategy”

“We have a Population

Health Management

Strategy”

Why move to population health?

• Unsustainable rising healthcare costs

• Not meeting quality standards

• Comparatively poor health outcomes

A comprehensive population health business model provides a pathway to address these issues.

What is Population Health?• “The health outcomes of a group of

individuals, including the distribution of such outcomes within the group.”1

• Includes the distribution of health, not just the overall health of the population

1. Kindig, DA, Stoddart G. (2003). What is population health? American Journal of Public Health, 93, 366-369.

http://ajph.aphapublications.org/cgi/content/abstract/93/3/380

Many factors contribute to population health.

It’s estimated that clinical care contributes only 20%.

Modified from Isham G and Zimmerman D, HealthPartners Board of Directors Retreat, October 2010

Health Care (20%)

Access to & Quality of:•Preventive Services•Acute Care•Chronic Disease•End of Life•Cross Cutting Issues

• Tobacco Non-use• Activity• Diet/Nutrition• Alcohol Use

Health Care System’s mission is to deliver high quality health care services

Health Behaviors (30%)


Population Health System’s mission is to improve health

Improved Health

(as measured by Summary

Measures of Health)

Health Care (20%)


Socio-economic Factors (40%)

Environmental Factors (10%)



Community-identifiedDrivers (Advocacy and Participation)



Improved Health

(as measured by Summary

Measures of Health)

Key Outcome

HealthDeterminant

PrimaryDrivers

HEALTH CARE SYSTEM MISSION,CAPABILITIES, CONTROL

Health Care (20%)


Socio-economic Factors (40%)

Environmental Factors (10%)


• Central to Mission• Many Capabilities• High Control


• Central to Mission• Shared Capabilities• Shared Control

Community-identifiedDrivers (Advocacy and Participation) • Aligned with Mission

• Limited Capabilities• Limited Control


“…improving the public’s health at prices we can afford cannot and will not be achieved until basic financial and

managerial mechanisms and incentives are aligned to measures of health

outcomes…”

Source: Kindig, David. “Purchasing Population Health: Paying for Results” University of Michigan Press, 1997

Example: Health Care System Dashboard

• Clinical Quality and Patient Safety

• Access

• Patient Experience

• Margin

Example: Population Health System Dashboard

• Health Outcomes & Variation

• Community Investment

• Total Cost of Care

• Risk-Based Revenue

• Margin

Organization dashboards will need to support a population health system’s mission

to

Organization measures drive the actions to achieve the goal of improved population health

Outcome What we have to do…

Health Outcomes Improve health for populations and reduce disparities

Community Investment Coordinate efforts across all sectors contributing to

population health

Total Cost of Care Optimize and coordinate resources, in collaboration

with partners

Risk-Based Revenue Align contracts with desired outcomes

$ Margin Grow population base and decrease costs

The National Quality Forum has endorsed

health and well-being measures

Dehydration Admission Rate

Developmental screening using a parent completed screening tool

Well-Child Visits in the First 15 Months of Life

Immunizations for Adolescents

Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life

Ambulatory Care Sensitive Emergency Department Visits for Dental Caries in Children

Follow-Up after Emergency Department Visit by Children for Dental Caries

True

The United Kingdom

has created

measures of national well-being, aiming to

get beyond GDP

http://www.neighbourhood.statistics.gov.uk/HTMLDocs/dvc146/wrapper.html

Current measures are more disease management or process focused. Future health outcomes measures may look at:

• QALY

• Self-reported health status / well-being

• Move from disease management measures to prevalence measures e.g.

– Prevalence in kids: Obesity, Asthma, ADHD

– Prevalence in adults: Obesity, DM, HTN, Depression

• End of Life: % deaths match AD wishes

Health outcome measures will need to include an assessment of variation in outcomes and disparities.

Dane County “Race to Equity” report is one example.

Health systems can also begin to assess variation in quality performance across populations

% Met WCHQ Diabetes All-or-None Outcome – May 2015, UW Health patients

Community investment measures to assess CHNA alignment with:

–Community benefit reporting

–Community partnerships development

–Philanthropy

Community Health Needs Assessment (CHNA) priorities may be a useful tool to benchmark for community investment

This assumes a CHNA process that is:• collaborative across the community • analytically robust enough to guide priorities• includes disparities assessment

Locally, only 4.4% of WI hospitals’

community benefit expenditures in 2009 went to Community

Health Improvement

Services

Source: Bakken and Kindig. What Counts: Harnessing Data for Americas Communities. 2014 downloaded at: http://www.whatcountsforamerica.org/wp-content/uploads/2014/11/Bakken.Kindig.pdf

The Total Cost of Care includes all payments for a population

• Total = All components of Health Care – e.g. for given population all costs related to physician services,

inpatient, SNF, pharmacy, home health, hospice…– (& Population Health System?)

• Cost of Care– Cost to payers– Cost of production

Total Cost of Care includes the complete range of health care servicesFor Medicare patients, including beneficiary contribution, the average total cost of care is ~$1,182 Per Beneficiary Per Month (“PBPM”) for the following basket of services

How is ~$1,182 PBPM Spent?

Source: Data adjusted from 2010 Medicare Fee for Service Claims for illustrative purposes.

Figures include ~20% more PBPM to account for patient contribution

Healthcare in Transformation: Payment Reform & Accountable Care

Source: New York Times. September 7, 2015. “What are a hospital's costs? Utah system is trying to learn.”

“Recently, Dr. Porter and a colleague, Robert Kaplan, visited Utah and concluded that the hospital group was one of the few in health care to properly measure the costs of care. Elsewhere, with a very few exceptions, Dr. Porter said, “it’s a total mess.”’

Measuring cost of production will be more challenging.

“We have a foot in two canoes” can’t hold us back.

We live in a HYBRID WORLD.

Risk Based includes: full and partial capitation, shared savings, bundles, prospective payment

For example, at UW Health nearly half our total revenue is risk-based.

Risk management strategies will distinguish the medically homed and non-medically homed

• For medically homed: managing risk is focused on the entire continuum of care

• For nonmedically homed: managing risk is focused on episodes of care

Risk Based includes: full and partial capitation, shared savings, bundles, prospective payment

Two thirds of revenue generated by the Medically Homed population is risk-based.

Margin will depend on growing the population base rather than volume of services.Case example:

The benchmark optimal performance, based on the evidence, for XYZ procedure is 1/1000 risk adjusted population. Health system currently performs 2/1000. What is the strategy?

– Cut procedure volume in half?– Double population?

What capabilities are needed to move population health system

measures?

Developing a population health system will require an assessment and further development of key capabilities1. Comprehensive System of Care

2. Information, Data and Analytics

3. Partnerships and Business Development

4. Aligned Incentive Structures

5. Community Engagement and Advocacy

• Standardized Care Models• Evidence-based medicine tools• Supporting technology• Systems design and process improvement

# 1. Comprehensive System of Care

Comprehensive System of Health Care Components

• Public health services

• Comprehensive primary care

• Care coordination and case management

• Behavioral health

• Specialty medical

• Home care

• Long-term care

• Palliative care

• Hospice

• Acute care (ED, inpatient)

• Surgical care

• Tertiary / Quaternary / Trauma care

Each area above needs:A standard model to optimize resources and reliability

To be customizable for individuals and populationsTo be integrated and coordinated

Delivering the right care at the right time

6-20%6-20%

21-100%21-100%

2-5%2-5%

1%

Complex Care

Chronic Care

Preventive and Routine Care

Understanding our Population Population Health Management Programs

Palliative CareComplex Case Management: Primary CareComplex Case Management: Special Populations

Chronic Disease Management (RN Care Coordination)Behavioral HealthPrimary Care – Specialty Care Agreements/e-consultsChronic Care Bundles

Wellness and Prevention (Outreach, Pain Mngt)Acute/Urgent Care AccessAcute Care Bundles

Post-AcuteAmbulatory Pharmacy

Coord

inate

d t

o m

eet

ind

ivid

ual &

fam

ily

goals

Investment in technology capabilities will support population health management

– EHR• Communication across system of care• Pop health functionality (registries, health

maintenance, plan of care, shared decision making)

– E-visits and consults– Telemedicine

• Remote monitoring

Transforming our systems will require the following capabilities:

– CQI (Continuous Quality Improvement)– IE (Industrial Engineering)– EBM (Evidence Based Medicine)– HSR (Health Systems Research)

Standard model of care example:

Ability to make “overnight” and sustained improvements building on Primary Care standard model

Domain Measure Number and Description 2013 Rate

2013 Decile

2013 Actual

Points ^

2013 Actual

Domain %^

2013 P4P Points1

2013 P4P Domain

%1

2014 Rate

2014 Decile

2014 Points

2014 Domain

%

Patient/Caregiver

Experience

ACO #1: Getting Timely Care, Appointments, and Information 82.05 80 2.00

100%

1.85

93.57%

81.94 80 1.85

95.71%

ACO #2: How Well Your Doctors Communicate 93.23 90 2.00 2.00 92.89 90 2.00ACO #3: Patients’ Rating of Doctor 91.91 90 2.00 2.00 92.46 90 2.00ACO #4: Access to Specialists 84.08 80 2.00 1.85 86.54 80 1.85ACO #5: Health Promotion and Education 58.05 60 2.00 1.55 58.62 70 1.70ACO #6: Shared Decision Making 76.05 80 2.00 1.85 79.04 90 2.00ACO #7: Health Status/Functional Status 72.49 N/A 2.00 2.00 73.93 N/A 2.00

Care Coordination/Patient Safety

ACO #8: Risk Standardized, All Condition Readmissions 13.51 90 2.00

100%

2.00

71.79%

14.75 90 2.00

90.36%

ACO #9: ASC Admissions: COPD or Asthma in Older Adults 0.73 70 2.00 1.70 0.69 70 1.70ACO #10: ASC Admission: Heart Failure 0.97 50 2.00 1.40 1.03 50 1.40ACO #11: Percent of PCPs who Qualified for Meaningful Use (Double-Weighted) 87.69 80 4.00 3.70 97.93 90 4.00

0.00 73.12 70 1.70ACO #12: Medication Reconciliation 0.00 0 2.00ACO #13: Falls: Screening for Fall Risk 22.67 40 2.00 1.25 68.59 80 1.85

Preventive Health

ACO #14: Influenza Immunization 85.77 70 2.00

100%

1.70

80.00%

85.99 70 1.70

93.44%

ACO #15: Pneumococcal Vaccination 92.17 70 2.00 1.70 92.50 70 1.70ACO #16: Adult Weight Screening and Follow-up 56.06 50 2.00 1.40 72.97 60 1.55

ACO #17: Tobacco Use Assessment and Cessation Intervention 92.27 90 2.00 2.00 97.81 90 2.00

ACO #18: Depression Screening 0.34 0 2.00 0.00 54.72 90 2.00ACO #19: Colorectal Cancer Screening 79.31 70 2.00 2.00 83.76 70 2.00ACO #20: Mammography Screening 69.39 60 2.00 2.00 83.53 70 2.00ACO #21: Proportion of Adults who had blood pressure screened in past 2 years 78.17 70 2.00 2.00 67.52 60 2.00

DiabetesDiabetes Composite: ACO #22: Hemoglobin A1c Control (HbA1c) (<8 percent); ACO #23: Low Density Lipoprotein (LDL) (<100 mg/dL); ACO #24: Blood Pressure (BP) < 140/90; ACO #25: Tobacco Non Use; ACO #26: Aspirin Use

40.09 90 2.00

100%

2.00

97.86%

41.98 90 2.00

97.86%

Diabetes ACO #27: Percent of beneficiaries with diabetes whose HbA1c in poor control (>9 percent) 9.27 90 2.00 2.00 8.98 90 2.00

Hypertension ACO #28: Percent of beneficiaries with hypertension whose BP < 140/90 75.60 80 2.00 1.85 75.99 80 1.85

IVD ACO #29: Percent of beneficiaries with IVD with complete lipid profile and LDL control < 100mg/dl 65.39 70 2.00 2.00 69.34 80 2.00

IVD ACO #30: Percent of beneficiaries with IVD who use Aspirin or other antithrombotic 91.78 80 2.00 1.85 93.67 80 1.85

HF ACO #31: Beta-Blocker Therapy for LVSD 91.60 90 2.00 2.00 97.44 90 2.00

CADCAD Composite: ACO #32. Drug Therapy for Lowering LDL Cholesterol; ACO #33. ACE Inhibitor or ARB Therapy for Patients with CAD and Diabetes and/or LVSD

78.52 80 2.00 2.00 75.69 70 2.00

2013 Actual ^: 100% 2013

P4P1: 85.80% 2014 Actual: 94.34%

Significant improvements were observed and sustained across dozens of primary clinics throughout the region

# 2. Information, Data and Analytics• Analytics drive our ability to improve health

– Access to data (complete view)• From patients• From payers• From community partners• From health care partners

– Data structures to store, organize and combine data• Enterprise data warehouse – or equivalent• HIEs connection(s)

– Analytics capabilities to support System of Care• Pop health analytics functions

Example: This depicts our analytics system for our Adult Complex Case Management Program. Clinical staff receives a list of “at-risk” patients via a secure portal to be evaluated for the program.

An operational dashboard shows patient-level data

that an RN or social worker

might use to see information about

a patient at a glance.

Robust program evaluation allows for program refinement to support greater impact.

(per 100 patients)

“Common sense tells us that we should pay for the best results we can get, as we would when we purchase a car, a home, or a bag of potato chips. The complex

nature of health outcomes and expenditures, however, renders traditional market forces impotent, since the “perfect

information” requirement is difficult to achieve…”


#3. Partnerships and business development

• We need to develop structures and processes to support effective partnerships including:– Community partners

• community centers, schools, corrections, public health, parks etc.

– Health care partners• to fill gaps in owned system and meet geographical population

needs (denominator)• to partner on shared goals within communities or for overlapping

populations

# 4. Aligned Incentive Structures

• Incentive structures need to align with our outcome measures.

Incentives include:– System contracts – Funds flow between partners– Physician compensation– Management systems accountability (both

financial and performance assessment)

Payment models are

still evolving.

For example, MSSP works

well for organizations

with high baseline

expenditures, but not others.

# 4. Community Engagement and Advocacy

Population health management may not require a separate

organization structure, but can facilitate the development of new capabilities and alignment across

existing capabilities.

“Purchasing Population Health…to be the new definitional and incentive paradigm…will be

new, not in its concept or even its demonstration, but in that it will be built into

fundamental financial and organizational structures that transcend fad or ideology. …

Simply put, implementing such an approach to measure and pay for cost-effective improvement

in population health status is the best opportunity we have for bringing value to U.S.

patients and purchasers…”


considerations: transformation to a population health system stephanie berkson, mpa vice president...

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