innovative care delivery models: payor provider partnerships to improve health & lower costs

7/28/2019 Innovative Care Delivery Models: Payor Provider Partnerships to Improve Health & Lower Costs

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Marci Nielsen, PhD, MPH

Chief Executive Officer, PCPCC

April 17, 2013

Innovative Care Delivery Models:

Payor Provider Partnerships toImprove Health & Lower Costs


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Features of innovative models

2

Baseline health assessment

Social and medical needs

Assessed in outpatient or inpatient setting Can be developed by health plan or provider

Inventions based on patient needs

Range of social service options

Facilitated by EHR/HIT Patient engagement and activation

Coaching in self-management

Team based care

Link to primary care

Interdisciplinary care team Mental health services

Care giver support

On-going monitoring

Links medical system & community

Care Coordinator

Individualized care planning

Support for home environment


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Delivery

Reform

Payment

Reform

Public

Engagement

Benefit

Redesign

Transformation requires


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Patient = Consumer = Voter

4IOM (2002); modified from Dahlgren and Whitehead (1991)


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5

Why is the Patient-Centered

Medical Home (PCMH) getting somuch attention?


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Source: Congressional Budget Office, The Long Term Budget Outlook, August 2010

Federal Health Care Costs

6

5


7/34Source: Center for American Progress, 2012

Unsustainable growth of health spending


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Source: Center for American Progress, 2012

Projected cost of health care


9/34Source: Center for American Progress, 2012


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Health care expenditure per personby source of funding, 2007*

3,307

4,005

2,618 2,726 2,844 2,7582,124

2,4462,056

3,092

449589 510 360

441

890

720

1,350580 246 470

528571

542

2,716

38

88

20479 343

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

US NOR SWITZ CAN FR GER SWE AUS* UK ITA

Out-of-pocket spending

Private spending

Public spending

* 2006Source: OECD Health Data 2009 (June 2009), Commonwealth Fund

Dollars*Adjusted for Differences in Cost of Living10


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Conservatively, 30% of

the annual $2.5

trillion U.S. health

expenditure isestimated to be

waste, equating to

approximately $700B

each year.

Key sources ofwaste1

% of totalmedical costthat is waste

Admin and system

Provider inefficiencies

Lack of care coordination

Unwarranted

Preventable conditions and

avoidable care

Fraud andabuse

4 - 6%

3 - 4%

1 2%

11 - 21%

1 - 2%

5 - 8%

~30%

1

Thomson Reuters, 2011

Cost of health care waste

11


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Solutions point to primary care

SignificantproblemsRising healthcare costs

$2.4 trillion (17% ofGDP)

Gaps/variations inquality and safety

Poor access to PCPs

Below-averagepopulation health

PCMHs

ACOs

EHR/HIE investment

Disease-management

pilots

Alternative care

settings

Patient engagement

Care coordinationpilots

Health insurance

exchanges

Top-of-license practice

Experiments underway

Across 300+ studies,better primary care

has proven to increase

quality and curtail

growth of health care

costs

Primary care-centric projects

have proven

results

Aging population

Chronic disease

12


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13

What are we actually referring to

when we say PCMH?


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14 Source: www.ahrq.gov

What is a medical home?The medical home is an approach to primary care that is:

Committed toquality and safetyMaximizes use of health IT, decision

support and other tools

AccessibleCare is delivered with short

waiting times, 24/7 access andextended in-person hours.

CoordinatedCare is organized across the

medical neighborhood

ComprehensiveWhole-person care provided by a

team

Patient-Centered

Supports patients in managingdecisions and care plans.


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A Change in Paradigm

Today Future

Treating Sickness / Episodic Managing Population

Fragmented Care Collaborative Care

Specialty Driven Primary Care Driven

Isolated Patient Files Integrated Electronic Record

Utilization Management Evidence-Based Medicine

Fee for Service Shared Risk/Reward

Payment for Volume Payment for Value

Adversarial Payer-Provider

Relations

Cooperative Payer-Provider

Relations

Everyone For Themselves Joint Contracting15


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Health IT Infrastructure

PCMH and Accountable Care:Two Sides of the Same Coin

Accountable Care

PCMH

PCMH

PCMH

PCMH

PCMHHospitals

Public Health

Shared ServicesCare Coordination

Care Managers

Specialists

16


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HITInfrastructure:EHRs andConnectivity

Primary CareCapacity:PatientCentered

MedicalHome

OperationalCare

Coordination:Embedded RNCoordinatorand Health PlanCareCoordination $

Value/OutcomeMeasurement:Reporting ofQuality,Utilization and

PatientSatisfactionMeasures

Value-BasedPurchasing:ReimbursementTied toPerformance onValue

Supportive Base

for ACOs, PCMHNetworks, andBundledPayments

Trajectory to Value-Based PurchasingIt is a journey, not a fixed model of care

17 Source: THINC - Taconic Health Information Network and Community


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Private Sector Payment

Reform Only 11 percent of payments create

incentives for providers to meet quality

standards, improve quality, or reduce

waste.

57% are at -risk arrangements --bundled payment, capitation (as well as

partial-capitation or condition-specific

capitation), and shared-risk payment

arrangements.

35% of non-FFS payments includequality is a factor

19


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Transparency: Health Plans

98% of plans offer/support a cost calculator 77% of hospital choice tools have integrated

cost calculators

77% of physician choice tools have integratedcost calculators

86% of plans report benefit design details(copays, cost sharing, and coverage exceptions)

Only 2% of total enrollment use thesetools

20

Source: National Scorecard on Payment Reform, 2013


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Contact:

Marci Nielsen, PhD, MPH

Chief Executive Officer

[email protected]

www.pcpcc.net


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What does the data tell usabout the PCMH?

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Improving individual health toimprove population health

Acknowledging driversof health behavior and

health status

Moving away from

patient educationtoward patient self

engagement

Working at

institutional and policylevels to focus on

patient

23

McGinnis et al., Health Affairs 21(2):78-93 (2002).


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New PCPCC Publication

Provides nationwide results from34 recent peer reviewed and

industry reports

health care costs

acute care services

quality of care

Provides additional information

on 23 case studies outlining

specific features of a PCMH

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PCMHInitiative

Health Care Cost &Acute Care Service

Measures

Health Outcomes &Quality of Care

Measures

BCBS Michigan:Physician GroupIncentive Program

13.5% fewer ED visits amongchildren

10% fewer ED visits amongadults

7.5% lower use of high-techradiology

17% lower ambulatory caresensitive inpatient admissions

6% lower 30 day re-admissionrates

60% better access to carefor participating practicesthat provide 24/7 access(as compared to 25% innon-participating sites),2008-2011

North Carolina:

Community Careof North Carolina(Medicaid)

3% lower ED utilization and

costs

25% lower outpatient care

costs 11% lower pharmacy costs

Improvements in asthma care 21% increase in asthma

staging

112% increase in influenza

inoculations

25


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PCMHInitiative

Health Care Cost &Acute Care Service

Measures

Health Outcomes& Quality of Care

Measures

Vermont BluePrint for Health(2011)

Lower inpatient admissions(range of 39.7 % to 15.3%)

Lower ED admissions (range33.8% to 2.8%)

Increase in visits forchronic care &behavioral health

CareMore (2011)MedicareAdvantage(California)

24% lower inpatient admissionrates (compared to Medicareaverage)

15% reduction in overall healthcare costs

97% patient satisfaction Hospital stays 38%

shorter Amputation rate for

diabetics 60% lower

Pediatric Alliancefor CoordinatedCare (Boston)

Reduction of inpatienthospitalization from 57.7% to43.2% (post implementation)

Reduction of parents missedwork(>20 days) from 26% to14%

Increased satisfactionwith health caredelivery (68.4% easierto talk with same nurse,60.9% easier to talkwith doctor, 60.5%easier to get access)


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WA

OR

TX

CONC

LA

PA

NY

IA

VA

NE

OK

AL

MD

MT

ID

KS

MN

ME

AZ

VT

MOCA

WY

NM

IL

WIMI

WV

SC

GA

FLHI

UTNV

ND

SD

AR

INOH

KY

TN

MS

AK

Overview of Commercial Health PlanMedical Home Activity

Multipayer pilot discussions/activity (30 states)

Identified pilot activity (49 states)

No identified pilot activity (1 state)

Source: Patient Centered Primary Care Collaborative, updated October 2012.

DE

NH

RIMA

CT

NJ


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Examples of Industry Investment


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Overview of CMS Innovation Center PCMH Initiatives


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Overview of CMS Innovation Center PCMH Initiatives

Demonstration

Multipayer AdvancedPrimary Care Practice

Demonstration

Federally Qualified HealthCenters (FQHC)

Advanced Primary Care

Practice Demonstration

Comprehensive Primary Care

Initiative (CPCI)

Geographicscope

ME, MI, MN, NC,NY, PA, RI, VT

500+ clinic sitesin 44 states

Seven markets:

Statewide: AR, CO, NJ, OR;Mid-Hudson/Capital (NY);Cincinnati-Dayton (OH); andGreater Tulsa (OK)

Participants

Up to 1,200 practices(MD & NP) participatingin state health carereform initiativespromoting APCP

FQHCs (and look-alikes)serving relatively largenumbers of Medicarebeneficiaries

45 payers (commercial, states,unions)

500 primary care practices 2,144 providers serving an est.

313,000 Medicare beneficiaries

Practicequalifications

Dependent on stateprogram

> 200 Medicarebeneficiaries per site

High-performing practices

Targetedbeneficiaries

Dependent on stateprogram

Medicare beneficiaries Medicare beneficiaries

Payment

Care management fee,established by statemultipayer reform

initiative

Medicare all-inclusive rateplus $6.00 PMPM caremanagement fee

Average $20 PMPM (risk-adjusted) years 12

Average $15 years 34

Opportunity for shared savings

starting in year 2


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Patient Engagement in Care Management for


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Patient Engagement in Care Management forChronic Condition

* Health care professional in past year has: 1) discussed your main goals/priorities in care for condition; 2) helpedmake treatment plan you could carry out in daily life; and 3) given clear instructions on symptoms and when toseek care.

Base: Has chronic condition.Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

Percent reporting positive patient engagementin managing chronic condition*

D t P ti t R l ti hi d C i ti


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Percent reporting positive doctorpatientrelationship and communication*

DoctorPatient Relationship and Communication

* Regular doctor always/often: spends enough time with you, encourages you to ask questions,and explains things in a way that is easy to understand.Base: Has a regular doctor/place of care.Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.


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Patient-Centered

Comprehensive

Coordinated

Accessible

Committed to

quality and

safety

A team of care providers is wholly

accountable for patients physical

and mental health care needs

includes prevention and wellness,

acute care, chronic care

Ensures care is organized across

all elements of broader health

care system, including specialty

care, hospitals, home health care,

community services & supports, &

public health

Delivers consumer-friendly

services with shorter wait-times,extended hours, 24/7 electronic or

telephone access, and strong

communication through health IT

innovations

Demonstrates commitment to

quality improvement through use

ofhealth IT and other tools to

ensure patients and families make

Dedicated staff help patients navigate

system and create care plans

Focus on strong, trusting relationships withphysicians & care team, open communication

about decisions and health status,

compassionate/culturally sensitive care

Care team focuses on whole person and

population health

Primary care could co-locate with behavioral,

oral, vision, OB/GYN, pharmacy, etc

Special attention paid to chronic disease and

complex patients

Care is documented and communicated

effectively across providers and institutions,

including patients, primary care, specialists,

hospitals, home health, etc.

Communication and connectedness is

enhanced by health information technology

Implement efficient appointment systems to

offer same-day or 24/7 access to care team

Use ofe-communications and telemedicine

to provide alternatives for face-to-face visits

and allow for after hours care

EHRs, clinical decision support, medication

management to improve treatment &

diagnosis.

Establish quality improvement goals; use

data to monitor & report about patient

Feature Definition Sample Strategies Potential Impacts

Patients are more likely to seek

the right care, in the rightplace, and at the right time

Patients are less likely to seek

care from the emergency room

or hospital, and delay or leave

conditions untreated

Providers are less likely to

order duplicate tests, labs, or

procedures

Better management of chronic

diseases and other illness

improves health outcomes

Focus on wellness and

prevention reduces incidence /

severity of chronic disease and

illness

Lower use of ER & avoidable hospital,

tests procedures & appropriate use

Why the Medical Home Works: A Framework

Supports patients and families to

manage & organize their care and

participate as fully informedpartners in health system

transformation at the practice,

community, & policy levels

innovative care delivery models: payor provider partnerships to improve health & lower costs

Documents