MHMD and Accountable Care
A Culture for Change
Chris Lloyd, CEO MHMD and MH ACO
March 28, 2016
Agenda
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Healthcare Macro perspective
Why do we create a culture for change?
Building Physician Leaders
Culture Change Implications
2
Memorial Hermann
Network Coverage Area
MH Health System
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$5.5B Total Assets
23,000 Employees
11 Acute Care Hospitals
225 Locations
24% Inpatient Market Share
MHMD Physician Network
 2,000 ACO Physicians
 400 Patient-Centered
Medical Home Physicians
 >650 total PCPs
 Additional 800 Specialty
Physicians from University
of Texas Medical School (UT
Health)
3
Memorial Hermann
Corporate Structure
System Quality
Corporate
Members
Children’s
Finance
Memorial
Hermann Health
System
Governance
Physician Council
Memorial
Hermann
Foundation
HePIC
Audit
MH
Accountable
Care
Organization
MH
Community
Benefit Corp.
MH Medical
Group
MHMD
MHealth, Inc.
MH
Information
Exchange
4
MHHS National Safety and
Quality Leadership
15 Top Health Systems;
Top 5 Large Health
Systems (2012,2013)
Healthcare’s “100
Most Wired” 7th
consecutive year
National Patient Safety
Texas Hospital Association
Leadership Award,
Joint Commission-NQF
Bill Aston Quality Award
Sponsored by VHA National Quality Forum
John M. Eisenberg
(2011)
Foundation & the
National Quality
National Patient Safety
National Business Healthcare Award (2009) & Quality Award (2012)
Group on Health (2009)
America‘s #1 Quality Hospital
for Overall Care
(2011 & 2012)
HealthGrades®
 America’s 50 Best Hospitals
(2010, 2011 & 2012)
 Distinguished
Hospital for Clinical
Excellence (2011)
2011 Texas Healthcare
Foundation Quality
Improvement Awards
(9 Memorial Hermann
Campuses)
Preparing for Change
So Why Change?
Changing our Thinking Population Management
7
Private Sustainability
Cumulative increases in health insurance premiums, workers
contributions to premiums, inflation and workers’ earnings
180%
168%
160%
160%
140%
120%
98%
100%
93%
80%
60%
50%
40%
24%
20%
38%
21%
0%
1999
2000
2001
2002
2003
Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits,
1999-2011. Bureau of Labor Statistics, Consumer Price Index, U.S. City
Average of Annual Inflation (April to April), 1999-2011; Bureau of
Labor Statistics, Seasonally Adjusted Data from the Current
Employment Statistics Survey, 1999-2011 (April to April).
2004
2005
2006
2007
2008
2009
2010
2011
Health Insurance Premiums
Workers' Contribution to Premiums
Workers' Earnings
Overall Inflation
8
Healthcare – A Flawed Model
How it will have to function
How the industry has functioned
Physicians, hospitals, and insurers working in
silos
 Willingness to depart from old models and
change roles of key players
Lack of data sharing across the functions that
touch the patient
 New technologies enable data flows to all
providers wherever the patient presents
Billboard Medicine - Management of a single
occurrence, not the population
 Focus on population health, prevention, and
the patient outside the health care setting
Patient engaged after becoming sick
 Proactive patient engagement
Inadequate transparency and access to data
 Transparent sharing of data among providers
and between providers and insurer
Lack of population management tools and
comprehensive data
 Population management tools employed and
informed by data to give 360o view
Misaligned incentives between providers and
insurers
 Aligned incentives reward providers and
hospitals for improved quality and cost
Disease and care management only an
insurer function
 Providers and insurer collaborate on disease
& care management to maximize impact
Little focus on systemic improvement
 Investment in continuous improvement
9
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©2011 Aetna
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9
Health Reform
by any other Name….
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Accountable Care Organizations
Affordable Care Act
Population Health
Clinical Integration
ObamaCare
Patient Centered Medical Homes
10
It’s Time To Upgrade
The Two Curve Problem
Current Model
New Model
Fee-for-Service
Disparate Payments
Illness & Cure
Volume Incentive
Fragmentation
Fixed Payment
Bundled Payment
Population Health
Value Incentive
Integration
Where We Need to Be
Where We Are
11
Accountable Care
What is needed to drive the
Quality & Cost Equation?
QUALITY
 Organizational Culture
 Structures that are foreign to traditional
delivery models
COST Medicine
 Commitment to Evidence Based
 Information Technology
 Uncharacteristic partnerships with
uncharacteristic partners (Payors, IT,
service providers)
12
Was our culture ready to function
address new models?
4 Key Strategic Inflection Points
 Clinical Integration & The Clinical Programs
Committees (CPCs)
 The Physician Compact
 The Patient-Centered Medical Home (PCMH)
 The Accountable Care Organization (ACO)
and Single Signature
13
Clinical Integration as our
foundation….
Clinical integration is
Integration of Physicians with each other (and
often with a hospital or hospital system) on a
Clinical basis to
 Determine the right and best ways to practice
medicine
 Commit to practice that way
 Commit to mutual accountability
 Develop active performance improvement t enhance
healthcare quality and efficiency
14
Tenets that have driven the development of
MHMD and the Accountable Care Organization
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Dedicated physician/administrative leadership
Physicians accountability to the organization and each other – The Compact
We do what is right for the patient
Evidence Based Medicine
Cost and Quality focus married with transparency of data
Leverage physician membership
Deliberate strategy and market approach
Partnership/Integration with an acute care provider network is fundamental
Active management of the culture at all levels
Physician employment agnostic
Focus on alignment of incentives
Ability to function as a large multi-specialty medical group – exclusive
representation
Defragmentation of the market
Now, Population Management and Accountable Care
15
MHMD Compact – 2008
The Basic Tenets of the Compact:
use of evidence-based medicine
collaboration with each other
willingness to be held accountable
willing to participate in committees
highest quality of care
16
Our compact defines
our mission
17
MHMD Compact
18
Compact Attestation
19
2016 MHMD CPC Structure
MHMD
Full CPC
Innovation
Primary Care
Transitions
of Care
Inpatient
Hospital-Based
Hospital
Medicine
MHPP
Cardiovascular/
CV Surgery
Surgery
Critical Care
Clinical
Compliance
FP/IM
Post Acute
Radiology
Hospital
Medicine
Cardiology
Perioperative
Surgical Home
Bariatrics
Critical Care
System MIC
Pediatrics
Supportive
Medicine
Perioperative
Nephrology
CV Surgery
Orthopedic
ORL
DVT JOC
Ambulatory
MIC
Allergy &
Immunology
PM&R
Pathology
Neurology
General Surgery
Neurosurgery
Sepsis
Acute Care Med
Informatics
Obstetrics/
Gynecology
Emergency
Medicine
Infectious
Disease
Robotics
Blood
Management
Neonatology
Vendor /
Supply Chain
Gastroenterology
Trauma
Behavioral
Medicine
Pharmacy
&Therapeutics
Hematology/
Oncology
Diabetes
Ethics
Professional
Performance
Improvement
Authority of the MHMD CPCs
System-wide quality engine
Delegation from the health system
 Protocols (creating and measuring EBM practices and order set
templates)
 Performance (setting and monitoring progress against established
quality standards and protocols)
 Products (drives the standardization of vendors, formularies, supply
chain decisions)
 Payment (Pay for performance goals, co-management agreements,
ACO project metrics, PCMH elements)
 Projects (ED to ED transfer policy, CT scanning in pediatric head
trauma, standardized order sets in Observation units, service line,
credentialing and privileging standards)
 Program Rationalization (Consolidation and concentration of clinical
service delivery – ie open heart and joint programs)
21
CPC delegated authority from
the System Quality Committee
“Up and Over”
BOARD SYSTEM
QUALITY COMMITTEE
Hospital MECs (11)
Clinical Programs Committee
Critical
Care
Surgery
Medicine
Med Staff
MHMD Board of Directors
High Reliability Certified Zero
Awards 2011-2016
ICU Central Line Associated Bloodstream Infections (15)
ICU Catheter Associated Urinary Tract Infections (7)
Hospital-Wide Central Line Associated Bloodstream Infections (5)
Hospital-Wide Catheter Associated Urinary Tract Infections (3)
Ventilator Associated Pneumonias (23)
Surgical Site Infections
Retained Foreign Bodies (41)
Iatrogenic Pneumothorax (19)
Accidental Punctures and Lacerations (3)
awards
Pressure Ulcers Stages III & IV (30)
Hospital Associated Injuries (6)
Deep Vein Thrombosis and/or Pulmonary Embolism (1)
Deaths Among Surgical Inpatients with
Serious Treatable Complications
Birth Traumas (14)
Obstetric Trauma in Vaginal Deliveries with Instrumentation (2)
Serious Safety Events 1&2 (14)
Serious Safety Events 1 & 2 for 1000 Days (2)
All Serious Safety Events (1)
Early Elective Deliveries (4)
Manifestations of Poor Glycemic Control (15)
205
23
2016 MHMD CPC Structure
MHMD
Full CPC
Innovation
Primary Care
Transitions
of Care
Inpatient
Hospital-Based
Hospital
Medicine
MHPP
Cardiovascular/
CV Surgery
Surgery
Critical Care
Clinical
Compliance
FP/IM
Post Acute
Radiology
Hospital
Medicine
Cardiology
Perioperative
Surgical Home
Bariatrics
Critical Care
System MIC
Pediatrics
Supportive
Medicine
Perioperative
Nephrology
CV Surgery
Orthopedic
ORL
DVT JOC
Ambulatory
MIC
Allergy &
Immunology
PM&R
Pathology
Neurology
General Surgery
Neurosurgery
Sepsis
Acute Care Med
Informatics
Obstetrics/
Gynecology
Emergency
Medicine
Infectious
Disease
Robotics
Blood
Management
Neonatology
Vendor /
Supply Chain
Gastroenterology
Trauma
Behavioral
Medicine
Pharmacy
&Therapeutics
Hematology/
Oncology
Diabetes
Ethics
Professional
Performance
Improvement
The Patient-Centered
Medical Home
Quality
Innovation
Technology
UC/AH
Retail
Clinics
Care Mgmt
Disease Mgmt
Health Coaches
Preventive Care
Data
Discounts
Liability Ins
Group
Purchasing
Single
Signature
Contracts
Gap Reports
At Risk/High Risk
Physician Report Cards
Pt Engagement
Patient Education
Physician Training
HCC
Documentation
ICD-10
CMEs
MU University
Physician University
Patient
Access
Patient Portal
Supp Medicine
Post Acute
Ambulatory ICU
Claims Files
EMR data Lab Rx
Practice Transformation
EMR
Point of Care
NCQA
Practice Assessment
GNE
Program
Clinical Integration | Accountable Care Organization
Informed Physician
Better Care
Great Experience
Primary Care Network
>400 Adult & Pedi Medical Home Physicians
North Region
Northeast Region
60 APCPs
Region Leader – Dr. John Walker
27 APCPs
Region Leader – Dr. Tejas Mehta
West Region
70 APCPs
Central Region
Region Leaders – Dr. Ankur Doshi &
Dr. David Reininger
56 APCPs
Region Leader – Dr. Kevin Giglio
Southeast Region
SW Region
76 APCPs
Region Leader – Dr. John Vanderzyl
48 APCPs
Region Leaders – Dr. Maqsood Javed &
Dr. Adnan Rafiq
26
Organized primary care builds the ACO
Gr Houston >11,000
MHMD 4,000
CI 2,900
Clinically Integrated IPA
Private, Employed & Faculty Integration
Exclusive Contracting DOJ/FTC Protections
ACO 2,750
Health
System
PCMH 420
11 Independent Medical Staffs
3 Distinct Practice Models
Employment
Private
Faculty
27
The ACO opens doors
Commercial
MHACO
Medicare
 Shared Savings and Aligned Incentives
 More flexibility in ACO “related”
quality, safety and efficiency program
incentives
 MHMD “exclusive” contracting
capability
POPULATION MANAGEMENT
Quality Assurance And Improvement Program Processes
Promoting Evidence Based Medicine
Promoting Beneficiary Engagement
Internally Reporting On Quality And Cost Metrics
Promoting Care Coordination
28
Care Management
Infrastructure matures
Transitions of
Care Program
Complex Care
Program
Life in Balance
Virtual Care
Preventive
Care Gap
Services
Diabetes
Services
Health Coach
Services
Social
Services /
Psych
Response
Supportive
Medicine/
Hospice
Pharmacy
Services
29
BUILDING PHYSICIAN AND
EXECUTIVE LEADERS
Keeping our finger on the “pulse” of
the network
30
MHMD University
In keeping with one of the provisions of the MHMD Compact, Physician University is a new initiative to
enhance professional development and collaboration among our physicians and executives.
•
Participants complete a 10-session program
•
Each semester is built to have approximately 30 participants – a mix of MHMD physicians and Memorial
Hermann executives.
•
Physician University is conducted in collaboration with the Rice University Jones School of Business on
the Rice campus. Subjects are taught by Rice Business School faculty members together with senior
Memorial Hermann executives.
•
Each Session topic breakout:
•
•
•
•
•
•
Leadership
Strategy
High Performing Teams
Accounting/Finance
Process Improvement/Quality and Change Management
Presentation of Projects
31
First Graduating Class - 2015
Physician Leaders in the Health System
Significant increase in physician leadership in governance process
System Quality
8/18
Medical Staff Applications
Division Quality (North)
Finance
2/5
Investment
12/34
Corporate
Members
Division Quality (Central/West)20/47
Division Quality (South)
MH Community
Benefit Corp.
(Internal Board)
Children’s Hospital
3/24
Memorial Hermann
Health System
27/27
2/7
HePIC
Compensation
2/17
Governance
Physician Credentials Advisory21/21
MH
Foundation
1/24
11/33
Physician Council
1/14
5/9
MH Accountable
Care
Organization
5/5
MH Medical
Group
MHS 5/5
Physicians of
Texas
MH Information
Exchange
(Internal Board)
Audit
1/11
Community Relations
1/15
21/21
MHMD
1/5
MH Health
Plan, Inc.
(Internal Board)
150: physicians
413: total “positions”
=36% participation rate
MH Health
Solutions, Inc.
1/5
MH Health Insurance
Company
(Internal Board)
33
#4. I believe the role of the MHMD Board needs to
evolve.
80%
70%
60%
50%
40%
30%
20%
10%
0%
Strongly
Disagree
Disagree
Neutral
Agree
Strongly
Agree
34
#5. Moving towards risk is an appropriate strategy for
MHHS/MHMD.
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Strongly
Disagree
Disagree
Neutral
Agree
Strongly
Agree
35
#6. Moving a “meaningful” amount of my practice to risk
contracting is acceptable.
40%
35%
30%
25%
20%
15%
10%
5%
0%
Strongly
Disagree
Disagree
Neutral
Agree
Strongly
Agree
36
Physician Quantitative Survey
MHMD Member Satisfaction
July 2014
Draft Copy
Majority feel promises are kept
All
Responses
Loyal
At-Risk
Exceeded all our expectations
7%
9%
0%
Exceeded some of our expectations
19%
24%
4%
They have been about what we
expected
59%
58%
67%
They have failed to deliver on some
promises
14%
9%
25%
They have failed on many of the
promises
1%
0%
4%
How do you feel about MHMD’s delivery on what you were promised
(Physician accountability, quality of outcomes, safety, and cost efficiency) at
sign up?
PAGE 38
At-Risk 3x
more likely to
report promises
unmet
n = 91
2015 Strategic Planning
Topic Survey Results
Powered by
The TOP THREE initiatives we felt have the
GREATEST IMPACT on our organization
Greatest Impact
Journey to Accountable Care
MHMD Board Governance
Integrated IT Systems
Growth Strategies
Cost and Quality Outcomes
0%
10% 20% 30% 40% 50% 60% 70% 80% 90%
40
The TOP THREE initiatives we felt have the
GREATEST SENSE OF URGENCY
Greatest Urgency
Journey to Accountable Care
MHMD Board Governance
Integrated IT Systems
Growth Strategies
Cost and Quality Outcomes
0%
20%
40%
60%
80%
100%
41
DATA AND
OUTCOMES
42
Success brings covered lives
Community Health Choice
109,000
United Healthcare Commercial
100,000
BCBS Commercial
75,000
TIER III Risk
United Healthcare Medicare Advantage
8,800
Humana Medicare Advantage
5,000
Aetna Medicare Advantage
5,800
546,400
Covered Lives
Humana Commercial
18,700
Aetna Commercial
85,000
TIER II Risk
CMS MSSP
47,400
Aetna Whole Health
26,200
Health Solutions Medicare Advantage
5,200
TIER I Risk
Health Solutions Commercial
MHHS 35,200 | Other 25,100
43
Population Health Data
SmartData
Longitudinal
Record
Gaps in Care
ClinicCare4
Web
Report
Analytics
Reports
Dashboards
Care Mgmnt
44
Year 1 & Year 2
Aggregate MSSP Savings
MH ACO
MH ACO
Palm Beach ACO
POM ACO
Oakwood ACO
Millennium ACO
ProHEALTH ACO
Allcare Options
Qualuable Medical Professionals
ACC of Texas
Mercy Health Select
West Florida ACO
Collaborative Health ACO
RGV ACO Health Providers
Quality Independent Physicians
Delaware Valley ACO
Physicians ACO
Methodist Patient Centered ACO
Reliance ACO
Maryland Collaborative Care
Premier Patient Healthcare
Lahey Clinical Performance ACO
ACC of Southeast Wisconsin
Integral Healthcare
Genesis APN
Winchester Community ACO
Seton ACO
Medical Mall ACO
New Health Collaborative
Optimus Healthcare Partners
Accountable Care Options
Integrated ACO
The Accountable Care Organization
Nevada Primary Care Network
WellStar Health Network
Independent San Diego ACO
Rio Grande Valley Health Alliance
AnewCare Collaborative
John Muir Health ACO
Circle Health Alliance
TP-ACO
WESTMED Medical Group
Coastal Medical
Paradigm ACO
HHC ACO
Cumberland Center
ACC of Maryland Primary Care
Virginia Collaborative Care
Southern Kentucky HCA
Ingalls Care Network
BHS Accountable Care
Generated Savings Yr 2
Generated Savings Yr 1
$-
$20,000,000
$40,000,000
$60,000,000
$80,000,000
$100,000,000
$120,000,000
Better cost and quality
for employers
1,600 ACO covered lives
Small Global Engineering and Construction Co.
Houston Energy, O&G industry
Medical Costs
Target
15%
lower
Actual
Enrollment
2014
20%
increase
2015
Efficiency Results
TARGET
RESULT
DELTA
Impactable Medical Admissions/1,000
55.0
16.7
69.6%
Potentially Avoidable ER Visits/1,000
95.4
65.7
31.1%
High Tech Radiology Visits/1,000
170.3
149.0
12.5%
CT Scans and MRIs/1,000
66.3
60.5
8.7%
46
Memorial Hermann
Employee Cost Trend
$12,000
$10,770
$11,000
Actual PEPY Claims
Cost
$9,910
$10,000
$9,190
$9,000
$8,444
$7,000
$8,869
$8,569
$7,747
$8,008
$7,664
$7,667
$7,664
$8,000
$7,162
$7,076
FY 2010
FY 2011
$9,328
MHHS Trended
PEPY Claims Cost
$8,391
National Trended
PEPY Total Claims
Cost
$7,724
$6,000
FY 2012
FY 2013
FY 2014
FY 2015
47
Clinical macro economics
got better
Before ACO
Impactable Admits /1,000
27.1%
lower
Impactable Medical Admits /1,000
26.6%
lower
Impactable Surgical Admits /1,000
28.3%
lower
Impactable Medical Bed Days /1,000
47.0%
lower
Impactable Surgical Bed Days /1,000
5.7%
lower
High -Tech Radiology Visits /1,000
42.4%
lower
CT Scans and MRIs /1,000
47.8%
lower
Efficiency Metric
After ACO
0
ACO Narrow Network, YOY performance
100
200
48
Supportive Medicine:
Impacts Cost Savings
Pre Consult
Post Consult
16%
Texas Medical Center
lower
18%
Memorial City Hospital
lower
The Woodlands Hospital
24%
Southwest Hospital
23%
Northwest Hospital
20%
Southeast Hospital
27%
lower
lower
lower
lower
$-
$1,000
$2,000
$3,000
$4,000
Average Cost Per Day
49
Practice Performance Review
Red = unfavorable
Green = favorable
Blue = neutral
Commercial Market
Metrics 2014
Memorial
Hermann
Other
Outcome
Inpatient PMPM
$88.91
$97.15
8%
Outpatient PMPM
$131.70
$137.18
Outpatient Procedures
$43.20
$53.83
Primary Care PMPM
$28.29
$33.07
Specialist PMPM
$116.59
$120.49
4%
20%
14%
3%
50
Impact on Board Governance







Increasing focus on quality
Increasing risk
Increasing bonus pools
Greater transparency in the data
Changing payment models (MIPS, APM)
Consolidation in the market
Board Development
51
Accelerating the design of the
Care Delivery Model
 Culture
 Structure
 Quality
 Partnership
52