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Making the Numbers WorkSession: PH3 March 5, 2018

Bruce K. Muma, MD, FACP

Matt Hussmann, MPH

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Muma, Bruce MD

Hussmann, Matt MPH

We have no real or apparent conflicts of interest to report.

Conflict of Interest

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Agenda

• Overview of Henry Ford Health System

• Taking the Plunge – Odds in Our Favor

• Strategic Approach – Hot Spots of Opportunity

• Data and Analytics – Building the Infrastructure

• Measuring Performance – Guiding the Journey

• Lessons Learned

• Critical Success Factors

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Learning Objectives

• Discuss details and critical success factors associated with transitioning to value-based care

• Identify business intelligence and financial analysis approaches that optimize organizational efficiency and effectiveness within various payment models

• Synthesize insights from successful business model strategies to ensure profitability and mitigate risk within population health management

• Translate the MACRA/Quality Payment Program into an actionable executive strategy for your organization

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• 8 hospitals, 200 care sites, DME, Home Care, Pharmacy, 30,000 employee’s serving > 1M lives in Michigan

• EPIC EMR with advanced EDW platform, 2017 Davies Award winner

• Comprehensive physician organization:

Henry Ford Medical Group: 1300 physicians & scientists, 26 medical centers

Henry Ford Physician Network: 2000+ employed and independent physicians

Henry Ford (Next Gen) ACO: 1400+ physicians on HF instance of EPIC

• Provider-owned health plan (HAP), 650,000 members

• Diversified, comprehensive retail services

• 3.2 million digital encounters, including MyChart portal, e-visits, and mobile telehealth visits

Henry Ford Health System Organizational Snapshot

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Taking the Plunge

• Early creation of ACO network – one of the first in Michigan (2010)

• Opted not to pursue Pioneer ACO opportunity (2012)

• Shared savings threshold

• Adverse impact of IME/DSH payments

• Retrospective attribution (HFHS EMR resources not yet fully implemented)

• Opted not to pursue MSSP opportunity (2014, 2015)

• Same reasons and savings threshold even worse

• Selected as one of 21 Next Generation ACO (NGACO) participants (2016)

• IME/DSH payment issue resolved

• Prospective attribution and 1st dollar shared savings

• Waivers helped remove care and cost management barriers

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Odds in our Favor?

• Large, academic health system serving as a safety net for an aging, underserved inner city population

• Regional referral center for several tertiary/quaternary centers of excellence

• Financial model and incentives aligned with volume based payment

• Local market not highly consolidated creating significant risk for “leakage”

• Potential to leverage learning/support from owned health plan (HAP)

• Potential to leverage EMR/EDW investment

– ACO providers required to be on our

instance of EPIC

– Simplifies data aggregation/reporting

• NGACO provides flexibility in financial model

– Upside/downside risk adjustable

between 80 – 100%

– Floor/Ceiling on losses adjustable

between 5 – 15%

• NGACO provides APM designation for

MACRA in early years

Perhaps Perhaps Not

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Next Generation

Target if Inefficient Target if Average EfficiencyTarget if Highly

EfficientHFHS Baseline (HFH estimated per capita costs - 2013) 12,145 12,145 12,145

HFHS Adjusted Baseline (Baseline with regional growth of 3.2%)2 12,534 12,534 12,534

HFHS Per Capita Growth at rate 389 389 389

Adjustments to Baseline:Target with Quality Discount (0 to1 %) -2.0% -2.0% -2.0%

Regional Efficiency (-1 to 1%) -1.0% 0.0% 1.0%

National Efficiency (-0.5 to 0.5%) -0.5% 0.0% 0.5%

Total discount -3.5% -2.0% -0.5%

Adjusted HFHS benchmark 12,095 12,283 12,471

Decrease Total Spend by 3%Total reduction from baseline (prior year) (7,300,000) (7,300,000) (7,300,000)

Medicare Scored "Savings" 6,300,000 10,000,000 13,800,000

Medicare Actual Savings (HFHS with 3.2% growth less 97% of HFHS Benchmark) 15,100,000 15,100,000 15,100,000

Shared savings 5,040,000 8,000,000 11,040,000 Increase Total Spend by 3% (Expected Growth Rate)

Total reduction from baseline (prior year) 7,300,000 7,300,000 7,300,000

Medicare Scored "Savings" (8,300,000) (4,500,000) (800,000)

Medicare Actual Savings (HFHS with 3.2% growth less 103% of HFHS Benchmark) 500,000 500,000 500,000

Shared savings (4,150,000) (2,250,000) (400,000)

Total Spend Maintained at Current Rate Total reduction from baseline (prior year) - - -

Medicare Scored "Savings" (1,000,000) 2,800,000 6,500,000

Medicare Actual Savings (HFHS with 3.2% growth less 103% of HFHS Benchmark) 7,800,000 7,800,000 7,800,000

Shared savings (800,000) 2,240,000 5,200,000

Sensitivity Analysis

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Strategic Approach• Use NGACO as a “tipping point” for HFHS Value Based journey – Socialize/Energize

– NGACO pushed HFHS (providers) beyond 33% of revenue in upside/downside risk

• Communicate/Advocate for Value Based Care:

– 40+ presentations to HFHS leadership bodies

– Synergize and integrate with allies (e.g., HAP, SNF Network, Care Management)

– Engage physicians (newsletters, articles, presentations)

• Engage beneficiaries

– Newsletters, phone hot line, EPIC MyChart enrollment

– Incorporate patient/caregiver convenience in design of new care models

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Strategic Approach

• Leverage the EMR/data/analytic platform (HELIOS)

– Clinical and claims data

– Risk prediction/benchmarking

– Performance dashboards

• Implement innovative care models to address the “hot spots” of waste

– Define framework, strategies, tactics

– Conduct ROI analysis

– Implement (as quickly as possible)

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Hot Spots of Opportunity

• Locate and define waste using available data and benchmarks.

– High/Rising Risk Populations (site of care)

– Acute Care Episodes (variation in medical decision making)

– Post Acute Care/Transitional Care (variation/outsourcing)

• Estimate impact of new care models/pathways (volume X unit cost)

– High Risk Populations – “top 5%” in prospective risk

– Acute Episodes – decision to admit, specialty referrals

– PAC – SNF LOS, readmissions

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2016 Actual Financial Performance - HFACO

Total Aligned Members: 20,330 (239,033 member months)

Total Benchmark Expenditures: $248,993,939.75 ($1,041.67 PMPM)

Total Performance Year Expenditures: $244,010,551.67 ($1,020.82 PMPM)

Total Savings after adjustments: $5,023,134.90 ($21.01 PMPM)

Shared Savings (80% of Total Savings): $4,018,507.92 ($16.81 PMPM)

Sequestration: ($80,370.16)

Net Shared Savings: $3,938,137.76 ($16.48 PMPM)

Achieved 2.0% savings from CMS benchmark target

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Value Based Care Programs

• Post Acute Care (PAC) Surveillance

• Emergency Department Disposition Support (EDS)

• Comprehensive Care Clinics (Ambulatory Intensive Care Units)

• Case Management integration

• Clinical Decision Support (Choosing Wisely/Referring Wisely)

• Non-domestic Hospitalist program

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Leveraging our IT Platform

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Key Enabler #1 – Patient Mastering

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Blend External & Internal Information

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Key Enabler #2 - External Claims• Able to see true performance of at-risk contracts

• Extensive initial effort rewarded

– Load Eligibility / Membership files first

– Determine a natural key for original, cancellation and adjustment of claims

• Only store the ‘final’ claim

– Normalize/map claims to other contract claims

• CMS and Commercial claims data structure look nothing alike!

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High Level Tracking of Populations

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Information at the point of care

Data is moved

upstream to

alert providers

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Dashboards & Scorecards for Programs

• Feedback loop to front line staff

• Program dashboards available to entire health system

• Staff scorecards available to program manager and employees

Own Your

Numbers!

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Future Directions

• Virtual Care Center for high risk populations

• System Integrated Palliative Care

• Radical convenience programs (EMR imbedded navigation, virtual care, outreach)

• Clinical Decision Support (broader EMR alert environment)

• Specialist variation in medical decision making

• Genomics for identification of most effective treatment

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Lessons Learned

• Perfect data not required – there is plenty of waste!

• Internal EDW analytic capability a required element in managing financial risk

• Build executive dashboard to allow tracking of performance for senior leaders

• Aggregation and analysis of claims/EMR data is hard - building trust with providers is harder

• Focus on the “large buckets” of waste and supporting providers to do the right thing (vs. imposing controls)

• Understand how to translate value based initiatives into traditional ROI models

– Revenue loss vs. capacity gain

– Adverse impact of volume based incentives

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Critical Success Factors

• Impossible to over-communicate the vision and expected challenges

• Engage clinical leaders as care processes owners and inspire them to create better models of care

• Multidisciplinary teams are vital for creating value across the horizontal continuum of care

• Build reliable metrics and dashboards to demonstrate value in population health programs in real time (as much as possible!)

• Engage finance team to fully understand and measure impact of value based care programs

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Questions

• Matt Hussmann: mhussma1@hfhs.org

• Bruce Muma: bmuma1@hfhs.org

• Please complete online session evaluation!!