the engelberg center for health care reform at brookings ... · medical homes integrated into...

The Engelberg Center for Health Care Reform at Brookings | The Dartmouth Institute

June 6–8, 2012

Third Annual National ACO Summit

Follow us on Twitter at @ACO_LN

and use #ACOsummit.

Community Based Accountable Care

National ACO SummitL. Allen Dobson, Jr., MDPresident and CEOCommunity Care of NC

Accountability, “Systemness”

& Incentives ( original ACO principles)

Establish robust HIT infrastructure

Implement cost-saving and quality-improving medical interventions

Evaluate performance at the system level

Restructure payment incentives to support accountability for overall quality and costs across care settings

Key Design Elements

Pay for better value – improved overall health while reducing costs for patients

Provide timely feedback to providers

Require providers to report on utilization and quality

New model: It’s the system - Establish organizations accountable for aims and capable of redesigning practice and managing capacity

Realign incentives – both financial and clinical – with aims

Core Principles

Clarify aims to emphasize better health, better quality care, lower costs – for patients and communities

Better information that engages physicians, supports improvement, and informs consumers

Community ACO Considerations

Geography- how large?, all inclusive?,expansion plan Leadership – who convenes? Who are the required

participants?, open network vs other arrangement, how to engage physicians and broad provider group

Structure- what structure is best? Not for profit vs other- collaboration is key!

Population- public payer (Medicaid/care) vs commercial vs all payer) scale important, the entire population in geographic area

Data- who provides data services? Shared utility? Public?

Incentives- are risk arrangements needed to drive delivery system reform?, what incentives or payment methods are beneficial in an incremental approach?

Key Elements

Network of medical homes ( Primary Care foundation)Additional local resources based on population

Care managers- embedded, transitional, high risk, specialty

Pharmacists

Mental Health

Palliative Care/other

Broad collaboration of providers ( specialists, home care, mental health, othersActionable dataDegree of transparency of performance metrics and outcomes ( shared accountability)

5

New Models of Care = New Data Needs1.

Deliver to providers more complete picture of the individuals being cared for

2.

Deliver to providers/communities a more complete picture of the population

we are ‘accountable’

for

3.

Couple performance measurement with actionable information (Don’t just measure quality, enable quality improvement!)

4.

Identify high-risk/ high-opportunity patients for targeted services

5.

Equip the care team with tools for providing patient- centered care

Patient-Centered Medical Home programs

More than 40 states have some aspect of Medical Homes

34 states have PCMH using National Academy for State Health Policy criteria

Central role now for NCQA criteria for defining and evaluating PCMH (Levels 1-3)

Most PCMH initiatives begun since 2008

Limited efforts: Pilots, short-timeframes, specific sites or regions.

Several recent PCMH efforts related to Health Homes for Chronically Ill (Sec. 2703).

7

PCMH payment models vary

PMPM payments in many states: (AL, CO, CT, IL, IO, LA, MD, MA, MI, MN, NY, OK, PA, SC, WA)

PMPMs can be based on a number of factors:Population Served

Child and adolescent

Age group

ABD

Practice size

Level of NCQA PCMH recognition (level 1- 3)

Shared Savings (LA, MD, MA, OR, PA, SC, WA)8

Community Accountable Care

Geographic Accountable Organizations (VT, OR, CO, RI, NC)

Aim to make populations they serve healthier to reduce rate of growth in costs.

Community-based focus to engage local leadership, stakeholders

Tailored to local needs and resources

9

Vermont’s effort

Community health teams led by a registered nurses

Registered nurses work within physician practices to:Track patients overdue for appointments or tests, manage short-term care for high-needs patients

Check that patients are filling prescriptions/taking medications

Follow up with patients on personal health management goals.

Also in primary care practices: behavioral health counselors; community health workers, dietitians

Referrals in both directions between primary care offices and social services.

10

Vermont’s effort

Medical homes integrated into Community Health Teams

Link primary care to community-based prevention of chronic disease. They offer

Individual care coordination, health and wellness coaching, and behavioral health counseling

Connect patients to social and economic support services

Perform community outreach to support public health.

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Vermont’s funding

Fee-for-service payments from insurers and Medicaid.

Plus PMPM that ranges from $1.20 to $2.39 based on NCQA score

Five full-time-equivalent staff members for each community health team ($350k/year shared by three commercial insurers and Medicaid.

Medicare to join Vermont’s Multi-Payer Advanced Primary Care Practice Demonstration pilot

12

Oregon’s effort

Local “Community Care Organizations” (CCOs) get lump-sum payment (“global budget)” – risk adjusted.

Communities have significant leeway in how they reimburse for services

Waiver of standard Medicaid requirements/ aggregation of health, behavioral health, dental health, developmentally disabled, and other specialized services

CCOs must reduce ER visits, identify/treat mental/ behavioral issues

Focus on primary/preventive care, patient responsibility

13

North Carolina’s Approach ( currently 1.4 million patients)

14 local, nonprofit networks led by clinicians (physicians, hospitals, health departments, etc.)

State PMPM to local network to provide on-the-ground care managers (600 over 100 counties), behavioral expertise, medication management from pharmacists.

Significant buy-in from clinicians/leaders – “our” quality standards and goals, not imposed from without.

Statewide informatics center provide real-time patient data at point of care; target “high preventables” to maximize ROI of interventions

Participating: 5,000 providers, 1,500 medical practices – 94% of NC primary care providers

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Community Care Networks

15

North Carolina’s Approach

State pays Fee-for-Service plus PMPM variable by population served (women/children vs. ABD)CCNC networks receive PMPM to provide care management, pharmacy services, behavioral consulting, etc.Portion of PMPM to Central Office for Informatics center, population management, health analytics, etc.

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Specialist Referrals

Self-Scheduling

Traditional primary care


Self-Scheduling

Transitional Care

Reporting/Alerts

Referrals

Network Care Manager

Network Pharmacist

Specialists

Network Transitional

Care Manager

Network Behavioral

Health

Network Palliative

Health

Network Social Worker

Medicaid of NC

Community Care of North Carolina

CCNC Networks

Dire

ct S

uppo

rt $$

Indi

rect

Sup

port

Dire

ct S

uppo

rt $$

Specialists

“Medical Neighborhood”Medical Home

Accountable Community

CCNC Today


Self-Scheduling

Transitional Care

Reporting/Alerts

Referrals

Network Care Manager

Network Pharmacist

Specialists

Network Transitional

Care Manager

Network Behavioral

Health

Network Palliative

Health

Network Social Worker

BCBSNC Medicaid of NC CMS-Medicare Other Payers

Community Care of North Carolina

CCNC Networks

Dire

ct S

uppo

rt $

$

Ince

ntiv

e $$

Indi

rect

Sup

port

Dire

ct S

uppo

rt $$

Specialists

“Medical Neighborhood”Medical Home

Accountable Community

CCNC Tomorrow

Quality Comes First, Savings Ensue

Managing transitions

190,000 NC Medicaid recipients admitted to the hospital each year; 31,000 multiple hospital admissions.

Nearly 1 in 10 admissions is readmission within 30 days of a previous discharge.

ABD only 25% of NC Medicaid recipients, but 40% of all inpatient admissions, two-thirds of potentially preventable readmissions, and 80% of total costs.

ABD – often multiple chronic physical and behavioral health conditions, polypharmacy, low health literacy, socioeconomic stress, and multiple physicians providing care.

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Managing transitions

Cross-hospital traffic common: 23% of readmissions within 30 days of discharge occur in a different facility.

Cross-region traffic common: for large referral centers (e.g., Duke and UNC), half of all patients come from communities outside of the locally affiliated CCNC network of primary care medical homes.

22

Data Use Case: Shared Statewide Pharmacy Home Process

Hospital ClinicHome NetworkTransitional Care

Manager (TCM)

Meets with Patient,

Gathers Discharge

instructions,

Counsels and Refers

to PCM

Primary Care Manager

(PCM)

Meets with Patient

at Home, Gathers

Drug Use inventory,

Assessment and

Self‐Management

Network Pharmacist

(PharmD)

Reviews All

Medication Lists

(Discharge, Home,

Claims) for

Discrepancies

CCNC Physician

(PCP)

Visit Scheduled,

PCP Receives

Problem List and

Care Coordination

Plan

(Patient Discharged from UNC, but lives in Onslow- Med Reconciliation Plus)

CCNC Pharmacy Programs Infrastructure

Network Pharmacist Director

Mental Health Director

Care Management Director

Clinical Directors Director

Quality Improvement Director

Care Manager

Network Pharmacist

Clinical Pharmacist (Practice Based)

Clinical Pharmacist (Hospital Based)

Scope and Reach of CCNC Transitional Care

Each dot represents the location of a person who received transitional care during a 6-month period from May –

October 2011.

Impact of Care Coordination

26

Impact of Care Coordination

27

Fouryear % Change in Preventable

Admissions and Preventable

Readmissions CCNC vs. Unenrolled

‐12%‐9%

26%

‐5%

‐15%

‐10%

‐5%

0%

5%

10%

15%

20%

25%

30%

PPAs PPRS

CCNC

Unenrolled

Treo Solutions

State Fiscal Year Per-Member, Per-Month Total Annual Savings

2007 $8.73 103,000,0002008 $15.69 204,000,0002009 $20.89 295,000,0002010 $25.40 $382,000,000

$984,000,000

Milliman CCNC savings estimate ( net cost of program)

Analysis of Community Care of North Carolina Savings, Milliman, Inc. December 2011

Lessons Learned

Physician leadership and collaboration is critical

Better health care system can start with public payers

Strong primary care is foundational to a high performing healthcare system

Additional resources needed to help providers better manage populations

Timely, actionable data is essential to success

Must build better local healthcare systems ( public-private partnership)

Improve the quality of the care provided and cost will come down

30

Additional information at:

www.communitycarenc.org

31

Track 7: Coordination Across the Continuum of Care

Panel 1: Community Based Accountable Care

L. Allen Dobson Jr., MD, FAAFP President, Community Care of North CarolinaHarold J. Apple President and Chief Executive Officer, Indiana Health Information ExchangeMichael P. Donahue, MBA Vice President, Payor Contracting and Relations, Eastern Maine Healthcare SystemsMichael E. Duggan, JD Chief Executive Officer, Detroit Medical CenterAaron McKethan, PhD Vice President, RxAnte, Former National Director, Beacon Communities, Office of the National Coordinator

for

Health IT (Moderator)

Enhancing Primary Care Access at AMCs: The Experience of NewYork-Presbyterian

June 2012

David Alge

Vice President, Strategy and Financial Planning

34

Primary Care Access is Restricted

Average wait time nationwide is 20.3 days

Source: The Advisory Board Company, “Transforming Primary Care”, 2010; 2009 Survey of Physician Appointment Wait Times, Merritt Hawkins & Associates

35

Primary Care Providers are in Short Supply

Source: Association of American Medical Colleges

36

Health Care Access for Adults Declined Since 2000

Source: Health Affairs, “A Decade of Health Care Access Declines for Adults Holds Implications for Changes in the Affordable Care Act”, May 2012; Source: National Health Interview Survey, 2000-10

37

4564

55

53

5555

60

45

56

63

42

0 20 40 60 80 100

Uninsured part year

Insured all year

<200% of poverty

200%–399% of poverty

400%+ of poverty

Hispanic

Black

White

2008

2005

2002

U.S. Variation 2008

U.S. Average

Percent of adults ages 19–64 with an accessible primary care provider*

Variable Access to Primary Care

* An accessible primary care provider is defined as a usual source of care who provides preventive care, care for new and ongoing health problems, referrals, and who is easy to get to and easy to contact by phone during regular office hours.Data: N. Tilipman, Columbia University analysis of Medical Expenditure Panel Survey.

37

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011

38

AMC’s Maintain Broad Patient Service Areas

16 County market includes includes New York, Bronx, Kings, Queens Westchester, Dutchess, Nassau, Orange, Richmond, Rockland & Suffolk counties NY, Bergen, Essex, Hudson, & Monmouth counties, NJ and Fairfield

county CT

39

Source: U.S. Census Bureau, 2010 American Community Survey-Public Use Microdata Sample; Population Division-

New York City Department of City Planning

2

Persons 5 years and over3

Persons 25 years and over

1

Includes Hong Kong and Taiwan

% Limited % High School % CollegeEnglish Graduate Graduate

Proficient2 or Higher or HigherTotal 8,185,314 24 79 33

Native-born 5,138,863 7 86 40Foreign-born 3,046,451 50 72 26

Dominican Republic 378,199 70 56 11China1 351,314 78 60 25Mexico 187,086 83 42 5Jamaica 169,863 1 78 19Guyana 138,549 2 77 19Ecuador 138,097 77 59 10Haiti 97,516 50 80 18Trinidad and Tobago 84,347 0 86 16India 72,803 38 82 53

Educational Attainment3

Total Population

Selected Socioeconomic Characteristics of New York City’s Top 10 Foreign-born Groups, 2010

….with Diverse Patient Populations

40

How AMCs are Responding

Primary Care Physician Employment

Increasing appointment availability & expand hours

Technology (Remote/online triaging of patients; E-visits)

Team-based care delivery

Patient-Centered Medical Home

Retail clinic partnerships

41

Enhancing Primary Care at NYP

42

The Five Campuses of NewYork-Presbyterian

Weill Cornell Medical Center(850 Beds)

Morgan StanleyChildren’s Hospital

(257 Beds)

Milstein Hospital(720 Beds)

Payne WhitneyWestchester(270 Beds)

The Allen Hospital(201 Beds)

Note: Total beds represent licensed beds

43

Affiliation with Two Premier Medical Schools1771 – New York Hospital 1898 – Cornell University

Medical College(Now Weill Cornell)

1927 – Affiliation Agreement

1868 – Presbyterian Hospital1767 – Columbia University

College of Physicians & Surgeons

1911 – Affiliation Agreement

1998: NewYork-Presbyterian HospitalOver 1,600 residents

120 ACGME-accredited programs

Single-site GME provider

Both highly ranked by U.S. News

http://en.wikipedia.org/wiki/Image:Pslogo-columbia.jpg

44

Overview of NYP’s Ambulatory Care Network 12 practices offer primary care and over 65 specialty services

Urgicare Center

7 School-Based Health Centers

4 Women, Infants, Children (WIC) sites

20 nutritional centers

Annual Volume

787,000 Visits

238,000 Patients

3,000 Visits per day

45

NYP Regional Health Collaborative

Goals

Provide Better Care

Measurably Improve Health

Contain and Reduce Costs

Better Position NYP for Health Reform

We are transforming the care we provide patients in the Washington

Heights-Inwood Community

46


Population Health Infrastructure /

Capability

47

NYP Regional Health Collaborative: Patient Centered Medical Homes

Information TechnologyE-scribing, E-tracking, E-alerts, E-registries, E-decision support

Patient Centered Medical HomeNCQA Certification (IT, 3 Chronic Diseases, Care Coordination)

Access to CareCall Center, ED, Specialty Care, Insurance Enrollment / Outreach, mynyp.org

Adult –

Diabetes and Heart FailurePediatrics –

Asthma Mental Health –

Adult and Adolescent DepressionWomen’s –

Gestational Diabetes

Develop Care Management Programs / Staffing and Operations

Cultural CompetencySkills-Based Training: Communication, Language Access, Health Literacy

ColumbiaDoctors, NYP (e.g., ACN, ED), Community MDs, VNSNY

48



Capability

49

Risk Stratification

ACN (Y/N)

Discharge Disposition

High Inpatient Utilization (6 or more discharges in ‘09 & ‘10)

Phase I NYP / CU High Risk Patient Population (Adult Med/Surg 2o DX Diabetes, Asthma, CHF)*

Diagnosis Exclusions

273 Unique patients accounted for 2,214 discharges in 2009 &

2010

Targeted Care Initiative: Patient Selection

*Began with total patient population of 12,594

Adult Med/Surg Patients with 2o DX Diabetes, Asthma, CHF

50

Patient

High Cost, Chronically Ill Adult Med / Surg Patients

Targeted Care Initiative: Intervention Framework

Comprehensive Discharge Planning and Education

Beginning on Day of Admission

Ambulatory Care begins

Engagement of the Patient with a Medical Home

Disease RegistriesCare Management

IT EnabledCultural Competency

Management of Transitions of Care

Emergency Department-to-Home

Hospital-to-Home

51



Capability

52

NYP Regional Health Collaborative Community Collaboration – Independent Community Physicians

Affiliate Status

EMR and Medical Homes

CCR/CCD Connectivity

Disease Management

mynyp.org

Access / Contact Center

Education Program

53

Healthy Children in the Heights (Childhood Obesity)

Heal 17 (Diabetes and Depression)

–

VNSNY, Community Physicians, Community Nursing Homes

UHF Seniors Living with Diabetes

Building Bridges Coalition (BBKH)

Community Based Care Transitions

–

Isabella, Hebrew Home

NY State Medicaid Health Home

NYP Regional Health Collaborative Community Collaboration – Community Based Programs

54



Capability

Health Information and Exchange

55

Health Information: Diabetes Care Dashboard (ADA 2010 Guidelines)

Physician Alert: Status of Action Items

56

Health Information: Diabetes Data

3,4143,660

4794▲ 24%

A1c Collection 12 Months Pre-Implementation

A1c Collection 6 Months Pre-Implementation

A1c Collection 6 Months Post Implementaiton

A1c Collection Frequency

2,466 2,484

3172▲27.7%

LDL Collection 12 Months Pre-Implementation

LDL Collection 6 Months Pre-Implementation

LDL Collection 6 Months Post Implementaiton

LDL Collection Frequency

7.997.93

7.67

A1c 12 Months Pre-Implementation A1c 6 Months Pre-Implementation A1c Post Implementation

Mean A1c Value

93.7995.88

94.08

LDL 12 Months Pre-Implementation LDL 6 Months Pre-Implementation LDL Post Implementation

Mean LDL Value

57



Capability

Health Information and Exchange

58

NYP Regional Health Collaborative: Results to Date

Source: Health Affairs, November 2011

59

Can We Meet the Need?

Stratification of Primary Care Need

Team Members Operating at the Top of their License

Expanding the Team Beyond a Purely Medical Model

Personal Accountability

Track 7: Coordination Across the Continuum of Care

Panel 2: Strategies to Expand Primary Care Access for AMCs

David Alge, MBA Vice President, Strategy and Financial Planning NewYork-Presbyterian HospitalMolly Coye, MD, MPH Chief Innovation Officer, UCLA Health SystemJerry Friedman, JD Advisor for Health Policy and Director, External Relations and Advocacy, Ohio State Medical CenterKatrina M. Lambrecht, JD, MBA Vice President & Chief of Staff, UTMB HealthDeborah E. Trautman, PhD, RN Executive Director, Johns Hopkins Medicine Center for Health Policy and Healthcare Transformation (Moderator)

The Engelberg Center for Health Care Reform at Brookings | The Dartmouth Institute

June 6–8, 2012

Third Annual National ACO Summit

Follow us on Twitter at @ACO_LN

and use #ACOsummit.

the engelberg center for health care reform at brookings ... · medical homes integrated into...

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