Transcript Document

Population Health Management:
Strategies and Tools You Can Use
March 19, 2013, 2:00 – 3:00 pm ET
Steven Christianson, DO
Medical Director VNS NY Homecare
President ESPRIT Medical Care,
Affiliated with VNS NY
Neil Smithline, MD, FACP
Director of Clinical Quality
National Medical Audit Division
Mercer Health and Benefits
Laurel Sweeney (moderator)
Senior Director
Health Economics & Reimbursement
Philips Healthcare
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Primary theme in health reform
Evident in ACOs, bundling, medical homes…
But what is it?
“Providing for all of the health needs of a specific
group of individuals as they move through the
health care system—and across the continuum of
care.”
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No longer tied to individual service or visit
Instead, based on the ability to improve the health
of a specific patient population
Changes represent major shift…
From
To…
Health system
Fragmented
Integrated
Care provided
Disjointed
Coordinated
Quality
Assuming it
Proving it
Payment base
Individual Services
Overall Value
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Medicare
Model
Population
Payment
Number of
entities
ACOs
Population
minimum
5,000, but
100,000s+
Reimbursement
based on meeting
quality, cost
metrics
250
Bundled
Payments
All patients; or
those with
specific
conditions
Reimbursement
based on costs,
quality metrics
500
Medical home
Patients of
Extra $ per
involved clinics patient
500
4
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What is real-world impact of population
health management?
What strategies/tools should you be using
now?
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Population Health Management:
Strategies and Tools You Can Use
The Philips Healthcare “Reimbursement Simplified” Webinar
Series Presents…
STEVEN CHRISTIANSON, DO, MM
MEDICAL DIRECTOR VNSNY HOMECARE
PRESIDENT ESPRIT MEDICAL CARE
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Agenda
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Brief Introduction
Definition of PHM
Drivers of PHM Expansion for Providers
What PHM Requires of Providers
What Providers Need to Meet PHM Requirements
PHM Strategies for Disease Management Providers
PHM and ACO Non-Cost Quality Measures
PHM Provider Incentives (2 Slides)
Example VNSNY Nurse/Hospital Transition Program (2 Slides)
Example ESPRIT Hospital/Health Plan/PCP Transition Program
Example ESPRIT Health Plan/PCP Community Intensive Care Program
SPARK©
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Population Health Management
Definition (PHM)
At the provider level, the Care Continuum Alliance*, an industry
group, has proposed the following definition of population health
improvement. The population health improvement model highlights
three components:
1. The central care delivery and leadership roles of the primary
care physician; the critical importance of
2. Patient activation, involvement and personal responsibility;
and the patient focus and
3. Capacity expansion of care coordination provided through
wellness, disease and chronic care management programs.
*Care Continuum Alliance, “Advancing the Population Health Improvement Model,
” http://www.fiercehealthit.com/story/hennepin-health-project-looks-build-countywide-ehr-program-national-implica/2012-01-10
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Drivers for Provider PHM
Expansion
• Rising Health Costs
– Employers develop wellness, disease management strategies
– Payors developing Value/Performance reimbursement models and shifting
risk to providers
– Medicare Hospital reimbursement penalties for readmission now and later
for not meeting quality standards
• Shortage of Primary Care Physicians, Key to PHM
– Increase in multidisciplinary team care delivery models led by advance
practice practitioners (e.g. Nurse Practitioners)
• Patient Affordable Care Act of 2010 (ACA)
– ACO development with accountability, collaboration and aligned incentives
for quality and care across the care continuum
– PCMH with focus on collaboration of providers with Hospitals
– Focus on multidisciplinary team based health care delivery
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What PHM Requires of Providers
For Providers to flourish with PMH
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Must think in terms of caring for an entire population and not just for
the individual patients who actively seek care.
Must supply proactive preventive and chronic care to all patients,
both during and between encounters with the healthcare system.
Must maintain regular contact with patients and promote and support
their efforts to manage their own health.
Care managers must actively manage high-risk patients to prevent
them from becoming unhealthier with complications.
Must use agreed to evidence-based protocols to diagnose and treat
patients in a consistent, cost-effective manner
Providers will continue to compete with one other, but they will also
have to work together to coordinate care and exchange health
information in a culture of shared responsibility.
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What Providers Need to Meet PHM
Requirements
• Provider Performance Incentives
– Attractive enough to encourage extra time and investment required for provider
organization/practice support capabilities for integrated care
• Provider Accountability and Joint Decision Making
– Commitment to collaboration with support for multidisciplinary
teams/intensivists that allow other clinicians to act on behalf of the PCP
– Care provided based evidence based protocols and care packages
• Information Sharing Capability
– Capability to provide access to all organization/practice clinical information
across the continuum of care to all clinicians interacting with a given individual
patient enrolled in an integrated care setting
• Provider Patient Engagement in Primary Care
– Care plan jointly developed with patient who agrees and commits to it
– Mechanisms established to allow tracking of patient compliance
– An annual risk assessment that promotes and provides programs for increasing
patient self-care not medical dependence
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PHM Strategies for Disease
Management Provider Programs
Survey of Disease Management Organizations*
43% have a PMH program, 80% PCMH participation, 60% ACO participation. Main
program components HRA, Health Promotion, Wellness Care Coordination,
Disease Management, Care Management
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PHM Team
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How Program delivered
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Telephone, patient Portal Print, Internet
Gap analysis feedback to providers
Member Engagement
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50%-60% Health Coach, PCP/Specialist’ Case Manager
30-40% Nurse Practitioner, Dietitian, Pharmacist
Preventive healthcare reminders
Web based education
Self management tools
Link to Community resources
Program Effectiveness Measurement
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Patient Satisfaction, Patient compliance
Clinical Outcomes
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*2012 Healthcare Benchmarks: Population Health Management, Healthcare Intelligence Network HIN
PHM ACO Proposed Non-Cost Related
Quality Measures
Proposed Baseline And Performance Measures For The “Triple Aim”
In Accountable Care Organizations: Proposed Non-Cost Related
Measures*
•First aim: health of population
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HEDIS: adults age 50 and older who received recommended colorectal screening
HEDIS: breast cancer screening for females ages 40–69
HEDIS: flu shot for adults age 65 and older
HEDIS: pneumonia vaccination status for adults age 65 and older
HEDIS: comprehensive diabetes care hemoglobin A1c controlled (< 8%) in adults ages 18–75
QUEST: prevention of nearly 30 measures of harm (composite score)
QUEST: observed to expected risk-adjusted mortality per 1,000 patients
QUEST: composite score of evidence-based care for hospitalized cases
•Second aim: experience of care
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HEDIS: global rating of all health care
HEDIS: global rating of personal doctor
HEDIS: global rating of specialist seen most often
*SOURCE Premier healthcare alliance. NOTES HEDIS is Healthcare Effectiveness Data and Information Set. QUEST is
Quality, Efficiency, Safety with Transparency.
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PHM Incentives for Providers
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Physician Quality Reporting System (PQRS) - report by submitting
specially designated quality measure billing codes that align with
evidence based clinical guidelines
– Used with Medicare provider PFP program in the ACA programs
– Payment penalty in the amount of -1.5 % of the “allowed charges,” in 2015
if not reporting in 2013
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Medicare PCP Bonus – Office, Home, and Nursing Facility visits
– 10% increase in fee schedule and allowances $200 for each Care Plan, and
$100 for each maintenance
– Allowed charges must equal 60% of Medicare payments for bonus
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Medicare Shared Savings (Accountable Care) Program
– A voluntary shared savings program that promotes accountability for
services to a Medicare population, goal quality and efficiency
– Regular FFS Medicare payments are augmented by additional payment to
the ACO for meeting quality and total expenditure goals, that are distributed
to the ACO providers
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PHM Incentives for Providers
(Continued)
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Enhanced Medicaid Reimbursement for Primary Care Services
• ACA increases Medicaid population ‘Medicaid Parity’ increased PCP
reimbursement rates to at least Medicare in 2013-2014
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Family Medicine, General Internal Medicine or Pediatric Medicine are
considered PCP. It also provides for higher payment for subspecialists related to
those specialty categories
Alternative Reimbursement Models
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Gainsharing, to share savings when participating in an integrated healthcare
system that meets goals for reducing healthcare costs
Bonus Payment usually for meeting quality and/or expenditure goal
Bundled payment to promote efficiency and increase collaboration
Member Incentives for PHM Participation
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Annual risk assessment patient preference for care determined
No co-pays deductibles or other cost barriers to PCP preventive and health
maintenance services
Incentive payment for DM participation HRA completion
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VNSNY Nurse/Hospital Transition
Collaboration
An initiative to collaborate with hospital discharge planners
and hospital programs
•On site embedded transition coordinator or program intake
coordinator gets referrals initiates episode
•Enhanced discharge planning with hospital programs and hospital
discharge coordinator
- Heart Failure, COPD, Diabetes
•Home visit episode – Patient and family/caregivers
- VNSNY evidence based disease protocols and teaching
aids, coaching, focus on self-management with tools
provided
- Medication reconciliation coaching on medication use
- Follow-up clinical appointment scheduling and coaching on
patient preparation for preparation
- Risk assessment with high risk provided direct call #
•Communication with PCP and other health care providers
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ESPRIT Hospital/Health Plan/PCP
Transition Program
ESPRIT’s Transitional Care Program is a 30-day intervention based on
the framework of Mary Naylor’s TCM and Eric Coleman’s CTI that
includes: In-hospital risk evaluation and stratification and
multidisciplinary transitional care planning, NP-led team (NP, RN, LCSW)
interventions via in-home and phone encounters:
•Introduced piloted and accepted by the hospital medical staff that
credentials the ESPRIT providers who deliver care in the program, paid
for by the health plan.
– The patient and their PCP must agree to participate to initiate
•An embedded trained Nurse Transition Coordinator performs intake risk
screening with evidence based tools
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Charleston Comorbidity Index (CCI), KATZ ADL functional status
Number of medications, inpatient or homecare in prior 6 month
Depression screen Patient Health Questionnaire (PHQ-2)
Cognitive status Six Item Screener (SIS)
Self perceived health status and change in health status
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ESPRIT Hospital/Health Plan/PCP
Transition Program(Continued)
Primary components of the 30 day episode
•Medical case management including NP/PCP and Health Plan case
manager collaboration on the medical plan
• Medication reconciliation
• Self management coaching (Colman’s 4 Pillars)
• Preparation for physician visits, joint visit if indicated
• 24/7 coverage by NPs for member and PCP
•Self-management education on managing changes in health
associated with multiple chronic conditions
•Identification of drivers of hospitalizations & interventions to
address gaps in care and reduce hospital admissions.
•coordination with and “hand-off” to a primary medical and/or mental
health home
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ESPRIT Transitional Care Program
Experience as of January 2013
Partnership with
Partnership with Plan B
Plan A and Partner Hospital
Partner
Hospital
 Program “Go-Live” Nov. 7,
2011
 Provided 519 evaluations and
95 (30-day) episodes of care
through 1/6/13
 ESPRIT/VNSNY coordinated
multi-organizational activities to
operationalize program at the
Hospital
 Program embedded a
Transitional Care Coordinator
into the hospital to perform
screening, risk assessment and
stratification and transitional
care planning
 Reduced all cause 30-day
readmission rate by 49%
(from 7.9% to 4.0%)
Plan A
ESPRIT
 Program initiated in Brooklyn and the
Bronx on Sept. 26, 2011
 Expanded to Manhattan & Queens on
October 26, 2011
 Provided over 500 evaluations and 30day episodes of care through 1/6/13
 Transitional Care Coordinator/NP has
conducted evaluations in multiple
hospitals
 Participation in Plan’s Medical
Management Rounds
 Achieved 91% PCP visit rate within
30-days of hospital discharge in a
population with a high rate of having
no active PCP
 Reduced all-cause 30-day
readmission rate by 45%
ESPRIT
(from 29% to 16%)
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Plan
ESPRIT Health Plan/PCP Intensive
Community Care Program SPARK©
Contracting with health plans for 30 day episodes of care this is a
community-based intensive care management program for patients with
serious chronic and/or life limiting illnesses who demonstrate a need for
intensive care management by repeat hospital/ED visits and/or high total
health care expenditures.
•Provided by an ESPRIT nurse practitioner led interdisciplinary team of palliative
care providers (Hospice collaborating MDs, NPs and LCSWs)
•Health Plan payment is by episode, but claims are provided documenting care
provided and capturing the ICD-9 and CPT codes.
•Care delivery is tailored to the individual, most with multiple comorbidities with a
blend of telephonic and home visits.
•Management of end-of-life members not eligible or refusing Hospice in collaboration
with their primary care provider (PCP) and coordinating with the health plan clinical
staff in case conferences
•Establishes member goals of care, which facilitates timely enrollment in Hospice, if
appropriate.
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ESPRIT Program Components SPARK©
Nurse
Practitioner
Case Manager, Team Leader and Co-Manager of Medical Services
Hospice
Physician
Primary Care
Provider
Collaborator
Coordination of
medical care
Patient/Caregiver
Health Plan CMO
&
Case Managers
Social
Worker
Psychosocial &
Behavioral Health
Interventions
Service Coordination
Community
Resources
Continued and future support
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ESPRIT SPARK© Program Results
• Financial
– 38% reduction in all cause hospitalization rates when compared to
the 12 months prior to SPARK admission
– 42% reduction in hospitalization in members (18%) with an
underlying serious (Axis 1) mental illness
– 20% lower total medical costs PMPM in patients enrolled in SPARK
≥ 6 months
• Clinical
– Patient Satisfaction: 100% of members surveyed in 2012 were
either satisfied or very satisfied with SPARK Program (N-66)
– 93% rate of completion of Advance Directives
– 93% rate of sustained or improved Quality of Life
– 54% enrollment into Hospice for Hospice eligible members (20% of
SPARK patients) and had an ALOS on Hospice of 66 days
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Useful Resources
An Internist’s Practical Guide to Understanding Health System Reform
http://www.acponline.org/advocacy/where_we_stand/access/internists_guide/
•This Guide is intended to serve as a practical resource for internists on health system reform legislation, the Patient
Protection and Affordable Care Act (ACA), enacted in March 2010. The Guide is organized by the year in which a policy
issue is to be implemented, making it easily apparent which new policies may be impacting physicians/patients
immediately.
Gaining Ground: Care Management Programs to Reduce Hospital
Admissions and Readmissions Among Chronically Ill and Vulnerable
Patients
http://www.commonwealthfund.org/Publications/Case-Studies/2013/Jan/Care-Transitions-Synthesis.aspx
•Three case studies illustrate the potential of care management programs to address this problem by improving care
coordination and transitions among high-risk patients. Study sites included two academic medical centers and a managed
care organization owned by a home health agency. The sites employed bundles of interventions involving multidisciplinary
teams to improve provider communication, patient and family education, care transitions from the hospital, and follow-up
ambulatory care.
ITH Population Health Management “A Roadmap for Provider-Based
Automation in a New Era of Healthcare.” http://ihealthtran.com/blast372.html
•This guide represents the first comprehensive effort to define a roadmap for providers that are exploring population health management (PHM).
The literature on patient-centered medical homes and accountable care organizations traverses some of the same fundamentals, but no other study
or report has yet provided practical guidance on how to set up the infrastructure that uses the latest health IT applications to facilitate and automate
PHM.
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POPULATION MANAGEMENT
It’s NOT “One size fits all”
March 19, 2013
Neil Smithline MD
San Francisco
What’s Your Goal
What’s Your Time Horizon
1o
Prevention
Low ROI
MERCER
1o
Prevention
Mod ROI
July 16, 2015
1o & 2 o
Prevention
High ROI
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Three Key Steps
We Fail at Step 2 and 3
1. Identify those at risk
From Knowledge to Action
2. Make sure they know what to
do
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SPECIFIC knowledge
-
Selective outreach
 Want to
do it!
3. Selectively activate the
population
– Two key tools
 Know
what to do
 Who’s at
Risk
MERCER
July 16, 2015
26
How Do We Help Members Change
Two Unique Tools for Targeted Outreach
IndiGO
PAM—Patient Activation Measure
• Using your existing data, targets
members and treatments with
greatest health and cost ROI
• Tells health coach how ready
each member is to manage their
own health
• Propels physicians and patients
into action
• Set goals and tasks that allow
member to succeed
MERCER
July 16, 2015
27
IndiGO—Propels Patients and Physicians into Action
Ms. Jones. By taking an ACE Inhibitor, you will
reduce your risk of heart attack and stroke by 31%.
And if you take a statin, you can get a further 18%
reduction.
• Providing this highly personalized message has been shown to
“activate” both physician and patient
– Physicians prescribe the right medications 4 times more often
– And patients fill their prescriptions 1.6 times more often
– Meds taken—6.4 times more often
IndiGO
• Targets treatments with greatest ROI for both member health and cost
• Then propels physicians and patients into action
MERCER
July 16, 2015
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PAM—Patient Activation Measure
No Way
 I’m not sure I
can do anything
to improve my
health.
Maybe
 I have the
confidence to
make changes,
but need to start
with small steps.
Starting
 I can make
needed changes,
but get stuck
when the going
gets tough.
Resilient
 Tell me what
to do and I can
do it—even in
times of stress.
• Highly activated members succeed with printed/web materials and minimal
support
• Less activated need frequent support/supervision—regardless of how sick they
are
• PAM lets you tailor scarce resources to the individual’s need, thereby
maximizing ROI
• Allows you to monitor program’s effectiveness at increasing member
activation—the key to improved self management
MERCER
July 16, 2015
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How to Execute
Where’s Your Population
High Regional Concentration
• Provider-driven population
management strategies
• ACOs
• Medical homes for the chronically
ill— and about to be chronically ill
• Require providers to highly train their
staff in skills like
– IndiGO
– PAM
– Motivational Interviewing
– Socially tailored messages
Change Culture
Dispersed Populations
Health Eats in
Cafeteria
• Vendors on steroids
Selective
incentives
• Good enough vs. best in class vendors
• Require vendors to highly train their
staff in skills like
– IndiGO
– PAM
– Motivational Interviewing
– Socially tailored messages
Walk 100 miles
with CEO
Registrie
s
Selective
reach out
I took the
Pro Health
pledge
MERCER
July 16, 2015
30
30
New Engagement FutureGRAM
Act on indicators of SK risk to effect a different future
• Use IndiGO and PAM to reduce
likelihood of acute episodes
– Exact value of potential action
(statins, exercise, etc.) in terms
of risk reduction
– Where and how each member
should focus his/her efforts
FutureGRAM : What are the details of
the problem? How big is it?
Which Actions Have Greatest Value
• Supplement with “Active
Education”
– Know your numbers
– Know (or choose) your PCP
– Support adherence to plan with
games, regret lotteries, and
incentives
MERCER
July 16, 2015
31
POPULATION MANAGEMENT
It’s NOT “One size fits all”
Activated Members = Healthy
Population
From Knowledge to Action
 Want to
do it!
 Know
what to do
 Who’s at
Risk
MERCER
July 16, 2015
32
Services provided by Mercer Health & Benefits LLC.
California Insurance License 0E75483
Questions?
Please type your questions into the video player window.
The moderator will pose questions to the panelists.
We would like to hear your views on today’s webinar. Go
to http://www.surveymonkey.com/s/JPHNYVB
For more information on reimbursement, please visit the Philips
Healthcare Reimbursement Website at
www.philips.com/reimbursement
34
Speaker Bios
Neil Smithline, MD, FACP
Director of Clinical Quality
National Medical Audit Division
Mercer Health and Benefits
Dr. Neil Smithline is responsible for overseeing the clinical standards associated with clinical performance management
engagements. Dr. Smithline has more than 35 years’ experience in the medical community, including academic positions at the
University of Arizona, College of Medicine and San Francisco General Hospital, UCSF. Over his career, Dr. Smithline has served as
chairman of the internal medicine department, the intensive care unit, and the department of nephrology at the Tucson
Medical Center and at El Dorado Hospital (Tucson).
Most recently, Dr. Smithline has been Mercer’s clinical lead for provider-based strategies—with medical group as well as large
health systems. In this capacity he has negotiated ground-breaking contracts with world-renowned health systems, as well as
innovative gainsharing agreements with medical groups that serve as templates for both medical homes and accountable care
organizations. Dr. Smithline has been clinical lead for Mercer’s Chronic-Patient Centered Medical Home model. He has
successfully implemented this model on behalf of individual employers, coalitions of employers, and Taft-Hartley Trusts.
Dr. Smithline has served several medical facilities as the medical consultant for clinical resource management, overseeing the
quality and appropriateness of care provided. Dr. Smithline’s focus has been clinical resource management, evidence-based
approaches to health care and medication management, patient risk management and medical cost reduction for hospitals,
physicians, employers and insurance carriers. He also has extensive experience in working with medical group design, practices
and reimbursement methods. Dr. Smithline is board certified in both internal medicine and nephrology, and he is licensed in
California. He received his BA from Tufts College of Liberal Arts and his MD from Tufts University School of Medicine.
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Speaker Bios
Steven Christianson, DO, MM
Medical Director, VNS NY Homecare
Owner/President Esprit Medical Care, Affiliated with VNS NY
Visiting Nurse Services of New York (VNS NY) is one of the oldest home care companies in the US, with a skilled staff of over
2,400 registered and advanced practice nurses, 400 rehabilitation therapists, 360 social workers, and 4,000 home health aids
providing expert home care services to 26,000+ patients daily and over 5.2 million visits annually in the NY City area. Dr.
Christianson is the medical Director of VNS HomeCare, which is the certified home care agency that supplies the nursing,
rehabilitative, and social services to patients.
Dr. Christianson is also the owner of Esprit Medical Care, which provides physician, nurse practitioner, and related professional
health services to patients mostly in the community and in their homes. The firm has a current staff of more than 90 fully
credentialed providers, and is affiliated with VNSNY.
From 1998 – 2009, he served as medical Director of VNS CHOICE Managed Long Term Care, a partially capitated Medicaid
long-term care health company. He also participated in all the planning and operational aspects and served as medical Director
of the VNX CHOICE Medicare Advantage Special Needs Plan HMO.
He holds a BA in Zoology University of California, Berkeley 1968; Doctor of Osteopathy medical degree, Chicago College of
Osteopathic Medicine 1973; with AMA Board Certification in Internal Medicine 1976, and a Masters in Management degree,
Kellogg Graduate School of Management, Chicago 1989.
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Questions?
Please type your questions into the video player window.
The moderator will pose questions to the panelists.
We would like to hear your views on today’s webinar. Go
to http://www.surveymonkey.com/s/JPHNYVB
For more information on reimbursement, please visit the Philips
Healthcare Reimbursement Website at
www.philips.com/reimbursement
37