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Steven Merahn, MD Chief Medical Officer
US Medical Management
March 18, 2015
Physician Community Webinar Series
Physician-led ACOs: Supporting Chronic Disease Management
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Welcome to the Physician Community Webinar Series Sponsored by the HIMSS Physician Community • A complimentary virtual event that will be held
monthly.
• Covers a wide range of topics on Medical Informatics, HIEs (Health Information Exchange), Standards and Interoperability, eMeasures and Quality Initiatives, and how it affects, impacts and involves physicians.
• For more information see www.himss.org/physician or contact Lauren Kaderabek at [email protected].
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Welcome to the Physician Community Webinar Series Sponsored by the HIMSS Physician Committee • Please insert all questions in the chat box located
on the bottom right of your screen.
• A copy of the recording and slides will be available for download within 24 hours on the Physician Community Webinar Series Archive Page www.himss.org/physician
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Moderator and Speaker
Moderator: Patricia L. Hale, MD, PhD Associate Medical Director for Informatics Albany Medical Center HIMSS Board of Directors Member
Speaker: Steven Merahn, MD Chief Medical Officer US Medical Management
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Speaker Bio: Steven Merahn, MD Steven Merahn, MD is Chief Medical Officer at US Medical Management, where he oversee clinical leadership of the for multi-state high risk ACO in the US. Dr. Merahn has had a diverse career as a physician executive, working many different sectors of the healthcare ecosystem from academic medical center administration to HIT product management and consulting.
A graduate of the Albert Einstein College of Medicine, he trained as a pediatrician and began his career as a Senior Medical Specialist with the New York City Department of Health, where he focused on policy and program development for child and family services
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USMM is the nation's leading provider of home based primary care for complex/chronic populations:
• Provide 15% of all in-home physician visits nationally • Serve over 50,000 complex patients on an annual basis; average
age 75 with 4+ conditions, 7+ medications • Operate >100 local offices across 14 States
Delivers a physician-driven, fully-integrated continuum of care model
~ 225 full time
Physicians, NPs
and PAs
Engage in over 400,000 physician house calls, 39,000 podiatric house calls, 139,000 home health visits, and 380,000 hospice patient days annually
Centralized administrative, data management, and call center operations
24x7 response to urgent escalations in illness and medical crises
Who We Are
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Continuum Model • Deliver an integrated continuum of medical services to meet patient needs in the
comfort of their own home • Physician / PCP as hub for care coordination ensuring alignment of treatment plans,
medications, etc. across delivery settings
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Results and Outcomes
• Provide enhanced access to health services and quality of life for complex populations by removing barriers to receiving care
• Integrated care model helps patients live independently longer, improves quality, promotes patient engagement, enhances medical outcomes and reduces medical costs
– 40% Reduction in All-Cause 30-Day Readmissions
– 50% Reduction in Hospital Admissions for Ambulatory-Care Sensitive Conditions
– 70% Reduction in ER Visits for Ambulatory-Care Sensitive Conditions
– 90%+ Patient Satisfaction Scores (CAHPS)
Pioneer ACO Cost Savings Independence at Home Cost Savings
Pioneer ACO Cost Savings (Year 1)Base Year Methodology (Used in ACO)Base Year Cost - Entire ACO (2011) $2,429.54USMM Control Year Cost (2012) $2,283.42USMM Cost Savings $146.12
% Savings 6.0%Medicare Advantage (For Illustrative Purposes)Patient HCC Score (Ex. Fraility Adj.) 3.13County MA Rate 4-Star (Wayne County) $847.13MA Calculated Reimbursement (2012) (ESRD Adj.) $2,728.18USMM Control Year Cost (2012) $2,283.42USMM Cost Savings $444.76
% Savings 16.3%
IAH Cost Savings Estimate (Year 1)USMM Year End IAH Beneficiaries 1,552Patient HCC Score (Incl. Fraility Adj.) 3.56CMS PMPM Average Adjusted Payment $3,322.00USMM PMPM Cost (Provided by RTI) $2,886.00USMM Cost Savings PMPM $436.00
% Savings 13.1%
USMM Estimated Total Savings $7.4M
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Today’s Top Three Take-Aways
This presentation will help participants:
• Understand the functional requirements of a population health infrastructure
• Clarify the THREE essential elements that create value in chronic care management
• Become familiar with the model for organizational mastery of population management
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Population Health Management
…is a transformational approach to
healthcare delivery that shifts the
focus from caring for patients who
self-select for care based on their
own assessment of their condition to
taking transcendent responsibility for
the health status of a cohort or
population of patients.
©2014 Steven Merahn, MD All Rights Reserved Not for publication or distribution without explicit permission of copyright holder
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HOWEVER, POPULATION HEALTH MANAGEMENT IS A METHODOLOGY FOR SYSTEMS-BASED
PRACTICE IRRESPECTIVE OF COMPENSATION MODEL
Population management has come to be associated with
evolutionary trends in payment or compensation for health
care services known variously as “accountable care” pay-for-
performance, or ‘fee-for-value”.
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…requires mastering a separate and distinct operating model from traditional care delivery, including a specialized infrastructure with its own functional requirements and
an associated set of operating capabilities.
Implementing Systems-Based Practice…
©2014 Steven Merahn, MD All Rights Reserved Not for publication or distribution without explicit permission of copyright holder
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What are the Goals for Systems-Based Practice?
• To manage variables in order to deliver or add “value”, where value is the maximum benefit for least “cost”
– Costs are not exclusively monetary: time, effort, resource allocation, burden, disruption, dissonance, reputation
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Delivering “Value”
• Delivering value requires building systems of practice that can deliver high-level quality-related performance across a population or cohort of patients using the most efficient levels of resources and services required to successfully achieve those goals.
– Program intensity is escalated and de-escalated based on patient needs, dynamics, outcomes and program efficiencies
Identifying the patients needing care is only a first step, how your
system engages and interacts with them is where the value is realized
OP
ER
ATIN
G
CO
ST
PERFORMANCE
Aetna Inc. DRAFT – Private and Confidential
In current models, patients self-select for care, which
provides little insight into the overall health status of others
©2014 Steven Merahn, MD All Rights Reserved Not for publication or distribution without explicit permission of copyright holder
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Self Selection Aligns with Fee for Service
Payer B
Payer C
Payer A Patient
A
Provider
Patient C
Patient B
Hospital
Under FFS, patients self-select for care and providers bills their payer
based on services delivered
Bill
Bill
Bill
©2014 Steven Merahn, MD All Rights Reserved Not for publication or distribution without explicit permission of copyright holder
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Population Management Supports Transition From Fee-For-Service to Fee-for-Value
17
Payer A
Patient A
Provider
Patient C
Patient B
Hospital In FFV, the Provider takes on responsibility for
quality of care and health of cohorts of patients and
renegotiates their relationships based
on value goals
In FFV, Provider compensation is based on their ‘accounting’ for their performance
against mutually agreed upon goals for
quality and health status
Report
©2014 Steven Merahn, MD All Rights Reserved Not for publication or distribution without explicit permission of copyright holder
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For population management, success is more than a full schedule and busy switchboard
Patients who do NOT come in for care
may be as important to
consider as those in the waiting room.
Aetna Inc. DRAFT – Private and Confidential
Analytics
Outreach and Engagement
©2014 Steven Merahn, MD All Rights Reserved Not for publication or distribution without explicit permission of copyright holder
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Payer A
Patient A
Provider
Patient C
Patient B
Hospital
Report Population Management
Analytics, Segmentation, Outreach, Care Management
HOWEVER, FFV requires providers to take on new roles and responsibilities, so they need to add new capabilities,
competencies and services
©2014 Steven Merahn, MD All Rights Reserved Not for publication or distribution without explicit permission of copyright holder
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Functional Requirements of Systems-Based Practice
Analytics /Reporting
Population Surveillance
Segmentation &
Targeting
Outreach & Engagement
The Functional Requirements of a Population Management Infrastructure: Systems Elements and Interaction Design ©2014 Steven Merahn, MD All Rights Reserved
Care Planning
Clinical Strategy
Resource Managed
Care Delivery
Care Coordination / Collaboration
Thresholds & Filters
System-Level Goals & Program Eligibility
Rules for Sorting &
Categorizing Data
Communication & Activation
Strategy
Resource Allocation &
Standing Orders
Programs & Services
Person-Level Goals, Shared
Decision Making, &
Coordination
Inputs
©2014 Steven Merahn, MD All Rights Reserved Not for publication or distribution without explicit permission of copyright holder
Data
Clinical, Claims, PDD,
Financial, Operational, Consumer
Generated Data
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Current View of Population Health Status
End of Life
Unstable Chronic
New Dx/Stable Chronic
Acute, Non Chronic
Wellness
The “pyramid” view of population health status reflects proportional distribution of risk and resource utilization, but does not serve as a rational basis for care planning and care delivery strategies.
©2014 Steven Merahn, MD All Rights Reserved Not for publication or distribution without explicit permission of copyright holder
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Population Health Management Requires Two-Level Care Plan Development
“Person- Level” Goals
“System-Level” Goals
©2014 Steven Merahn, MD All Rights Reserved Not for publication or distribution without explicit permission of copyright holder
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“Value” is created via the “Essential Triad”
Care Planning Care Delivery Collaboration
©2014 Steven Merahn, MD All Rights Reserved Not for publication or distribution without explicit permission of copyright holder
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Care Plan Framework
©2014 Steven Merahn, MD All Rights Reserved Not for publication or distribution without explicit permission of copyright holder
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Resource Managed Care Delivery
©2014 Steven Merahn, MD All Rights Reserved Not for publication or distribution without explicit permission of copyright holder
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Quality and Outcomes Are Humanity-Dependent
Dignity Authenticity
Integrity Empathy Sincerity Urgency
Emotive Performance
Tactical Performance
Efficiency Consistency Availability Reliability
Responsiveness Convenience
Products and Services
• Primary Care • Specialty Care • Inpatient Services • Centers • Lab • Imaging
Channels
• Call center • Web portals • Mobile apps • EHR/PHR • CRM/PRM
FINALLY… Clinical and operational performance alone is insufficient to meet the
performance goals for complex chronic care
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Improving the health status of individuals and populations fundamentally remains a human endeavor Thank You.
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Q&A
Steven Merahn, MD Chief Medical Officer US Medical Management
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Continuing Education Credit
• This program has been designated for 1 hour of CAHIMS credit.
• This program has been designated for 1 hour of CPHIMS credit.
• Download forms at www.himss.org/physician.
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SAVE the Date: Pharmacy Leads the Way with ePrescribing of Controlled Substances Pharmacy Town Hall Series
March 24, 2015 | 11:00 am central
Physician-led ACO’s: Opportunities & Challenges May 20, 2015 | 3:00pm central Physician Community Webinar Series
Register today at http://www.himss.org/physician
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Physician Community Website
• Please visit www.himss.org/physician for more information on:
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HIMSS Physician Engagement Survey
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Physician Activities: • Physicians’ IT Symposium • Physician Community Reception • Physician Poster Sessions • Opening Reception • Physician Interoperability Showcase Tour • Education Sessions • HIMSS Spot Meetups • HIMSS15 Block Party Contact Lauren Kaderabek [email protected] to get connected
April 12-16, 2015
www.himssconference.org