The Kaiser Way

Bernadette Loftus, MDAssociate Executive Director, The Permanente Medical GroupExecutive Medical Director in Charge, Mid-Atlantic Permanente Medical GroupSaskatchewan Medical AssociationMarch 2017

What is Kaiser Permanente anyway?

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“Kaiser Permanente Medical Care Program”

Kaiser Foundation Health Plan*

501(c)3 not-for-profithealth plan

Kaiser Foundation Hospitals*

not-for-profit Community hospitals

8 independentself-governedPermanente

Medical Groups**

* common Board of Directors

Health plan collects premiums from employers & government programs; premiums and cost sharing from individuals; takes risk for hospitalization, pharma, and owns capital.Medical groups coordinate provision of all medical services, ensure top quality and appropriate utilization; hold financial risk for all professional services, inpatient and outpatient.

**separate Boards of Directors**separate Boards of Directors

Why we’re so different

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*Prepayment *Prevention *Primary Care Primacy *Information Technology *Physician Collaboration and Leadership… all in our DNA thanks to an innovative solution between Sidney Garfield, MD (left) and Henry Kaiser (right)

Kaiser Permanente Today

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• 7 regions serving 8 states and D.C.

• Over 11.3 million members

• More than 21,580 physicians and 199,000 employees – every provider on KP HealthConnect®

• 38 hospitals (co-located with medical offices)

• 661 medical offices and other outpatient facilities – co-located primary, specialty, ancillary care

By the numbers• 101,368 babies delivered

• 44.7 million doctor office visits

• 980,741 mammograms

• 137,798 inpatient surgeries

• 78.3 prescriptions filled

• 1.9 million colorectal cancer screenings

• 5.37 million members registered on kp.org

• 22.3 million secure emails sent

• 40.5 million lab test results viewed online

• 19.3 million online prescription refilled online

• 4.7 million online requests for appointments

Data: Kaiser Permanente 2015 Annual Report

Kaiser Permanente today

Georgia318,407 members;12.0% growth YTD

Mid-Atlantic States701,170 members;

35,768 growth YTD; 40.1% growth in last 36 months;

5.4% growth YTD

Colorado675,035 members; 1.8% growth YTD

Hawaii252,369 members;1.1% growth YTD

No. California 4,119,696 members;

3.2% growth YTD

So. California4,386,079 members;

2.9% growth YTD

Northwest571,826 members;9.4% growth YTD

Data as of February 2016.

Geographies servedWashington

680,139 members;28,867 growth YTD

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Kaiser Permanente Value Strategy

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• Care providers isolated• Physician is sole point of care• Patients are poorly trained,

non-compliant• No evaluation of care• Discordant records

• Coordinated Care • Not exclusively physicians• Patients are educated• Measured accountability• Shared digital health history• Email routine questions

Fee for Service

Kaiser Permanente

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Integration in Fragmented World

How Kaiser Permanente delivers value: Integration

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Kaiser Permanente has comprehensive clinical data access and workflows to achieve coordination, elimination of waste, and quality

Disease registries

Risk stratification

Identification of subgroups needing care

Patient management tools

Targeted panel lists

Inreach - Prompts, reminders for clinicians

Outreach - Letters and automated telephone outreach to members

Monitoring and process improvement measures/reports

KP Health Connect

Secure Web-Based Universal Access Real Time Linked to Delivery System Electronic Ordering Digital Imaging Secure Messaging

Population Management Tools (enables wellness

& prevention) Labs

Inpatient

Outpatient

Emergency

Pharmacy

Imaging

Immunization

Membership

Financial &Benefits

KP.org and My Health Manager

Relentless for Quality Improvements

• How does KP consistently deliver superior quality care?– Not by accident but by design…

Quality is everyone’s job• Information at the point of care empowers

healthcare professionals

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Population Health Built-in Tools• Quality metrics measure and compare physicians

– Accountability, Transparency, Improvement

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Tackling Population Health….since 1933

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“Inreach”

• Every encounter

• Every location• Every specialty• Computer

prompted• Prospectively &

Retrospectively measured

“Outreach”

• Panel ownership

• Database management

• Slice & Dice• Phone, mail,

email• Comparative

physician level results

“Education”

• Physician accountability

• Lifestyle classes (online, in person, telephonic)

• In house nutritionists

• Exercise as vital sign

....in every specialty….

CULTURE…..

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450K

500K

550K

600K

650K

700K

'99 '00 '02 '01 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13 '14 '15 '16 17YTDFeb

Mem

bers

hip

Value achievement in quality and service drives differentiation and thus growth

KP Mid-Atlantic Membership Trend at Year End

• This region’s highest membership • KP’s fastest growing (third year in a row)

and 3rd-Largest Region • Cumulative net growth of 48.8% since 2009

701K

Focused execution drives the value equation: NCQA Results (current)

Based on 2016 NCQA data. NCQA is a private, non‐profit organization dedicated to improving health care quality. NCQA accredits and certifies a wide range of health care organizations. It also recognizes clinicians and practices in key areas of performance. NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS®) is the most widely used performance measurement tool in health care. Consumer Assessment of Healthcare Providers and Systems (CAHPS®) is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

National Committee for Quality Assurance (NCQA) annually rates nearly 600 Health Plans on clinical quality (using HEDIS) and consumer satisfaction (using CAHPS)*

PRIVATE PLANSHealth Plan NCQA Rating

KPMAS 5.0Johns Hopkins US Family Health Plan 5.0

Cigna Health and Life Insurance Company -Maryland

4.0

Johns Hopkins Employer Health Programs 4.0

Optima Health Plan 4.0

MD - Individual Practice Association Inc. 4.0

Aetna Life Insurance Company (MD/DC) 3.5

Aetna Life Insurance Company (Virginia) 3.5

Aetna Health Inc. (Pennsylvania) - Maryland 3.5

Coventry Health Care of Virginia Inc. 3.5

HealthKeepers Inc. 3.5

Anthem Health Plans of Virginia Inc. 3.5

Group Hospitalization and Medical Services Inc. (GHMSI)

3.5

CareFirst BlueChoice 3.5

Group Hospitalization and Medical Services Inc. (GHMSI)

3.5

CareFirst of Maryland Inc. 3.5

Cigna Health and Life Insurance Company -Virginia/District of Columbia

3.5

MEDICARE PLANSHealth Plan NCQA RatingKPMAS 4.5

Aetna Health Inc. (Pennsylvania) - Maryland 4.0Aetna Life Insurance Company (MD/DC) 4.0Aetna Life Insurance Company (Virginia) 4.0UnitedHealthcare Insurance Company - Maryland (Medicare) 4.0

UnitedHealthcare of Wisconsin, Inc.(South)-KY/NC/TN/VA 4.0

UnitedHealthcare Insurance Company - Virginia 3.5Cigna-HealthSpring Mid-Atlantic, Inc. 3.0Humana Insurance Company 3.0

For the second consecutive year, KPMAS earned a 5 out of 5 rating for Private plans

HEDIS 2016 Commercial KPMAS Best in Program for 21 measures of clinical excellence

Breast Cancer Screening – 5 years in a rowControlling High Blood Pressure – 2 years in a row

Human Papillomavirus Vaccine for Female Adolescents Comprehensive Diabetes Care - Blood Pressure Control

(<140/90) Comprehensive Diabetes Care - Eye Exams Weight Assessment and Counseling for Nutrition &

Physical Activity for Children/Adolescents Adult BMI Assessment

in the Nation on SEVENHEDIS 2016 Commercial

Measures

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Quantified Member Experience Achievement

Commercial CAHPS Competitor Regional ToplinesHealth Rating 2016

Name Type PLAN CARE

Kaiser Mid-Atlantic HMO 52% 56%Aetna MD/DC/VA HMO/POS 33% 42%

Anthem Blue Cross Blue Shield PPO 44% 52%

CareFirst HMO/POS HMO/POS 44% 49%

United Mid-Atlantic HMO/POS 31% 43%

HealthKeepers, Inc. HMO/POS 31% 44%

Optima Health Plan HMO/POS 37% 52%

NOTE: The source for data contained in this publication is Quality Compass® 2010, 2015 Commercial data and is used with the permission of the Committee for Quality Assurance (NCQA). Quality Compass 2010-2015 includes certain CAHPS data. Any data display, analysis, interpretation, or conclusion based on these data is solely that of the authors, and NCQA specifically disclaims responsibility for any such display, analysis, interpretation, or conclusion. Quality Compass is a registered trademark of NCQA. CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

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Value differentiation: Patient Experience (Service/Access/Satisfaction)

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8 Yearsin a Row!

KPMAS is #1 with J.D. Power & Associates

2016 Member Satisfaction Index Rankings Mid-Atlantic Region

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Completely Changing the Paradigm007 – Current: IHI “Triple Aim”

Relationships/Structure

LEADERSHIP

Leadership:What leadership roles should physicians play within the health-care system, and what capabilities and skills do physicians need to fill these roles?

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The Unique Qualities of Permanente Medicine

Physician responsibility for quality, service, design of operations and cost of care

Physician leaders emerge from clinical ranks; professionals leading professionals

Accountability exercised through self-managed and self-governed medical groups

Culture of both collective and individual physician accountability

Multispecialty Physician Leadership is King 20

• Performance matters

• “Value” is not a bad word

• Teamwork improves performance ( sacrosanct physician “autonomy” is not synonymous with quality)

• Integrate providers to improve communication and close gaps in care

• Maintain the altruistic vision

• Patients ALWAYS First 21

An Homage to Dr. Thomas Lee, formerly of Partners Medical Group: “Turning Doctors Into Leaders,” Harvard Business Review, March 2010

Actions…• Executives set bold goals & the context

within a broad vision Belief in what is achievable is source-based.

• Managerial governance in physician hands Ownership = Responsibility = Action

• Local leaders should have significant autonomy, but accountability still held firm A prescriptive approach merely “talks down to” a highly educated, motivated group… they just want the tools!

Physician Leadership Key Take-Aways

Set a high bar & clear vision

Set the What…not the How

Learn from each other

Principles

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A Theory of Lofty Goal Setting

Rapid performance improvement requires lofty, not the proverbial “achievable,” goal setting. That does not mean that lofty goals are not achievable. But unambitious goals will bring unambitious progress.

Locke, “Towards a Theory of Task Motivation and Incentives,” 1968Locke and Latham, A Theory of Goal Setting and Task Performance, 1990“clarity, challenge, commitment, feedback, complexity”

Collins and Porras, “big, hairy , audacious goals”, or BHAG’s, in Built To Last, 1994

Amabile and Kramer, “progress, not praise,” HBR, January 2010

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Focus, focus, focus – on flawless execution of a limited set of imperatives

It’s not enough to think Big Thoughts –implementation must be a core competency.

• A less-than-generous observation - lots of people like to dream up solutions, but fewer are willing to do the hard work of rolling up sleeves and getting it done. Reward the do-ers.

Think BIG, Start small, Move fast; if something is “imperative,” must create a sense of urgency around it

General Observations About Any Worthy Endeavor

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Relationships:

How can physicians be more fully integrated into the system, and how can the system better partner with physicians?

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Kaiser Permanente’s Secret Sauce –Dyad Leadership in Healthcare

• Physicians have decision-making authority over strategy development, finance, quality, care delivery, and more

• Every function has representation from both Kaiser Foundation Health Plan and Medical Group

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Physician Leadership and Involvement in Integrated Aligned System

• Aside from being direct care providers, physicians are involved in all aspects of the KP framework, from Benefits Committee (insurance coverage determinations), to resource stewardship, to capital planning, to quality improvement, and exercise primary authority over billions of dollars of KP revenue.

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Data and accountability:What data and analysis supports are needed to help physicians build evidence-informed improvement into practice? What does accountability look like within a redesigned system?

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Get it.

Share it.

Use it…

and

Data without leadership is just computer code.**

** Corollary: FOCUS and execution beat Big Thoughts

every day.

KP “Secrets” to Using DATA To Improve Care and Value

really,and relentlessly.

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Ask the right questions, so you can set the right goals

Which correlates best with favorable patient perception of speed of access to services?

1. Number of patients seen in a defined time interval

2. Actual length of interval to first available appointment

Get it

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Share the Data

Tailored to needs

Push it out,and deposit it

Challenge all to “Match the

best”

Local/regionalGroup/individual

In their handsIn the library

Transparency

Share it

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Getting the Data Right:Practice “data humility”

• It won’t always be right the first time

• Encourage people to find the mistakes

• Be transparent about correcting it

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FACT: Most low performers don’t know that they are, because no one ever told them.

If you don’t provide individual-level and unblinded data, everyone assumes it’s the “other guy” who’s “bringing down the average”.

Feedback is a Gift

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*Dunning, D., and Kruger, J. Journal of Personality and Social Psychology, 77(6):1121 -34, 1999

*Winners of a 2000 Ig Nobel Prize for this work

Unskilled and Unaware of It: How Difficulties in Recognizing One’s Own Incompetence Lead to Inflated Self-Assessments

The Principle of “Illusory Superiority”

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Actions…Data & Reporting Key Take-Aways

If you want to move something, measure it; you won’t move it unless you do

‘Some’ is not a number; ‘soon’ is not a due date – be specific in goal setting

You need both macro & granular results

Put the data right in the hands of influencers

Transparency… High & low performers should meet each other, and talk

Practice data humility

Pick your key metrics; set clear, specific goals

Be relentless in communication about patient care as driver for what we do, why we do it

Publicly report at geographic, department, team, & individual levels

Establish repository for reports so people have a reference library of performance

Challenge everyone to match the performance of the best

Publicly recognize and celebrate success! Actually use your data

Principles

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Compensation:How can we best align physician compensation models with improvements in patient care and physician work-life balance?

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Incentives

“Just the way we do things around here.”

Not really

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Driving Performance through Culture• Permanente physicians are all salaried, based

on competitive salaries in their specialties and geographic areas, and receive generous benefit packages.

• A small incentive bonus (usually less than 10%) is awarded if both the facility (practice site) and the individual physician achieve some specific quality and patient experience measures at the individual, department, and facility levels.

• Their performance in these areas compared to local and regional averages affects their bonus as well as their annual pay increase.

Payment scheme should favor the interests of patients (altruism).38

Physician Leadership Compensation

• Remunerated appropriately to convey and endorse policy, sanction change, and execute plans – in short, take on the mantle of leadership

• Protected administrative time to manage and lead a group to high levels of performance