HBCH – Local Health
System Strategies
Shawn Griffin, MD
Chief Quality and Informatics
Officer, MHMD
October 8, 2015
Major Trends
• Houston Price Pressures Increasing
• Health Systems Expanding Into Growing
Markets
• Payer, System, and Group Consolidation
Changing Existing Relationships
• Accountable Care Organizations Growing,
but Not All Systems Buying In
• Primary Care Affiliations Expanding
Traditional Healthcare –
A Flawed Model
How the industry has functioned
How it will have to function
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
Misaligned incentives between providers and
insurers
Disease and care management only an
insurer function
 Population management tools employed and
informed by data to give 360o view
 Aligned incentives reward providers and
hospitals for improved quality and cost
 Providers and insurer collaborate on disease
& care management to maximize impact
Little focus on systemic improvement
 Investment in continuous improvement
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Accountable Care =
Healthier Population
QUALITY
Doesn’t that sound
simple?
COST
Evidence-based Utilization
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A Very Basic Premise
MHMD
MHHS
Physicians
Hospitals
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Houston Landscape
Who you contract with “commoditizes” other parts.
Physicians
Multi-specialty
Groups
Medicare
Advantage
Plans
Hospitals
Ambulatory
Network
Post Acute
Multi-specialty
Groups
Medicare
Advantage
Plans
Payers
Hospital
Systems
Hospital
Systems
ACCOUNTABLE CARE ORGANIZATION
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How will we get there?
 Education
 Cultural Change
 Aligned Incentives
 Organizational Structure
 Commitment to Evidence Based Medicine
 Information
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We Started Many Years Ago…
5 Key Strategic Inflection Points




Clinical Programs Committees (CPCs) (2000)
Clinical Integration (2005)
The Physician Compact (2008)
The Patient-Centered Medical Home
(PCMH)(2011)
 The Accountable Care Organization (ACO)
and Single Signature (2012)
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Organization Timeline
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
CPCs
CPCs
Order Sets
FTC Consent Order
Crimson Development
Clinical
Integration
Discovery of CI
Commitment to eCW
PQRI reporting
Compact
CQIO, MHealth CI Contract
CI Bonus $
Order Set Delegation PCMH
CPC Restructure, IPA Partnership
POC, APCP Contracts
CI Bonus $
MHMD Care Management
IPQS
Data Analyst, Humana CI Contract MH ACO
Board Restructure, MSSP ACO
CPRM, NCQA Certifications
Aetna ACO Contract
CI Bonus $
BCBS ACO Contract
Pediatric APP Contracts
Network Management
Region Meetings
Supportive Medicine
Strategic Analytics, ScheduleNow
CI Bonus $
ACO Service Line Projects
Referral Center, Life In Balance
DocbookMD
MSSP Bonus$
Authority of the CPCs
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 – i.e. open heart and joint programs)
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Iatrogenic Pneumothorax
MH Southeast
hospital
MH
Southeast
Hospital
Ultrasound Mandatory
514 CPC
Recommendations
in 2014
20 Months
Zero Iatrogenic Pneumothorax
Clinical Integration (2005)
Participating physicians must participate
• Selecting quality measures
• Reporting performance
• Determining performance targets (setting realistic
goals)
• Participate in committee work, performance
feedback, and quality improvement activities
• Time, effort and IT infrastructure all required
Those who do not participate even after
remediation, must be removed!
MHMD Compact
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BUT WHAT WAS MISSING?
WHAT ABOUT OUTPATIENT?
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The Patient-Centered
Medical Home (2011)
Quality
Innovation
Technology
UC/AH Care Mgmt
Retail Disease Mgmt
Clinics Health Coaches
Gap Reports
At Risk/High Risk
Physician Report Cards
Preventive Care
Data
Discounts
Liability Ins
Group
Purchasing
Single
Signature
Contracts
Physician Training
HCC
Documentation
ICD-10
CMEs
MU University
Physician University
Pt Engagement
Patient Education
Patient
Access
Patient Portal
Supp Medicine
Post Acute
Ambulatory ICU
Claims Files
EMR data Lab
Practice Transformation
EMR
Point of Care
NCQA
Practice Assessment
Rx
GNE
Program
Clinical Integration | Accountable Care
Organization
Informed Physician
Better Care
Great Experience
Primary Care Network
>350 Adult & Pedi Physicians
North Region
60 APCPs
Region Leader – Dr. Ken Davis
Northeast Region
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
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Putting Inpatient and Outpatient performance
together when caring for whole populations…
WHAT DID WE LEARN ABOUT OUR
PERFORMANCE AS A COST &
QUALITY PROVIDER?
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Favorable Performance
Metric Trends
Aetna Commercial Data
Memorial Hermann is more efficient than the market
Inpatient Days/ 1000
208
13%
better
236
Average length of stay
3.5
11%
better
3.9
Re-admission rates
5.1%
6.0%
ER visits / 1000
164
8%
better
180
Memorial Hermann
18%
better
Houston market
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Along Came Health Reform
by any other Name….






Accountable Care Organizations
Affordable Care Act / Obamacare
Population Health
Clinical Integration
Patient Centered Medical Homes
And the ability to apply to become a
Medicare ACO participant
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Memorial Hermann ACO (2012)
System VAP
Do No Harm
Ventilator Associated Pneumonia
VAPs Rate per 1K Vent Days
6.00
4.00
UCL = 3.50
UCL = 2.88
UCLUCL
= 2.44
= 2.46
Mean = 2.04
2.00
Mean = 1.23
Mean = 0.95
LCL = 0.58
Mean = 0.64
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0.00
2006
Generated: 1/30/2013 12:18:11 PM
Source file date: 1/30/2013
2007
2008
2009
2010
2011
2012
Reporting Months
produce d by Sys te m Qua lity a nd Pa tie nt Sa fe ty
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What Does an ACO Mean?
 Allowed for collaborative aligned incentives
programs between hospital and physicians
 Relaxed fraud and abuse restrictions
 Provided for safe harbors
 Provided exclusive single signature capabilities
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AND THE PAYERS
RESPONDED TO OUR MODEL
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Covered Lives (2015)
BCBS (90,000)*
370,000+
Covered Lives
United (45,000)*
Aetna Whole Health (ACO) (26,000)
Aetna Commercial (85,000)
Aetna Medicare Advantage (5,800)
United Medicare Advantage (8,800)
CMS MSSP (ACO) (45,000+)
Humana Medicare Advantage (5,000)
Humana Commercial (18,700)
Health Solutions Commercial
(45,000+)
*estimated.
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Evolution of Partnerships
PAYERS
Health Plans
MHMD
Physicians
MHHS
Hospitals
DID IT WORK?
ARE WE MANAGING COST
& IMPROVING QUALITY?
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PARTNERING WITH
EMPLOYERS
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Clinical Economics Improved
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 Metrics
Impactable Admits /1,000
0
ACO Network, YOY performance
100
200
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Clinical Quality Improved
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Asthma:
Breast
Use of
cancer
appropriate screening
medications
Cervical
cancer
screening
Colorectal Diabetes: Diabetes:
cancer
Lipid profile Hemoglobin
screening
A1c testing
Aetna National
Average
2014 MHMD
Performance
Better Cost and Quality for
Employers
Global Engineering and Construction Co.
supporting Energy, O&G industry
Medical Costs
15%
lower
Target
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%
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BEST IN THE COUNTRY MSSP
PERFORMANCE
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MSSP Performance Year 1
(18mo)
MSSP ACO
State
Total Savings
ACO Share
TX
$57.83 M
$28.34 M
FL
$39.57 M
$19.34 M
NY
$27.92 M
$13.68 M
MI
$24.68 M
$12.09 M
RGV ACO Health Providers, LLC
TX
$20.24 M
$11.90 M
ProHEALTH Accountable Care
Medical Group, PLLC
NY
$21.91 M
$10.74 M
Triad Healthcare Network, LLC
NC
$21.51 M
$10.54 M
WellStar Health Network, LLC
GA
$19.88 M
$9.74 M
Accountable Care Coalition of
Texas, Inc.
TX
$19.10 M
$9.36 M
Memorial Hermann Accountable
Care Organization
Palm Beach Accountable Care
Organization, LLC
Catholic Medical PartnersAccountable Care IPA, Inc.
Southeast Michigan Accountable
Care, Inc.
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MSSP Performance Year 2
(12mo)
MSSP ACO
State
Total Savings
ACO Share
TX
$52.93M
$22.72M
FL
$32.17M
$14.46M
MI
$27.07M
$12.08M
Oakwood ACO, LLC
MI
$19.07M
$8.15M
Millennium ACO
FL
$17.49M
$7.98M
ProHEALTH Accountable Care
Medical Group, PLLC
NY
$17.15M
$8.02M
Allcare Options, LLC
FL
$16.99M
$6.06M
VA, TN
$16.62M
$7.41M
TX
$16.04M
$6.34M
Memorial Hermann Accountable
Care Organization
Palm Beach Accountable Care
Organization, LLC
Physician Organization of Michigan
ACO
Qualuable Medical Professionals,
LLC
Accountable Care Coalition of
Texas, Inc.
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What Employers Need to Do
• Expect Consolidation in Healthcare Market
• Recognize that Primary Care Relationship is Key
to Health for Employees.
• Push For Greater Transparency with Payers and
Conversations Directly with Providers.
• “Own” Wellness and Target Benefit Design to
Reinforce Goals.
• Align Incentives for Employees, Payer, and
Providers
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