Succeeding in the Reform Era
Jeff Moser, Vice President
Sg2
August 2, 2012
www.sg2.com
Agenda
What is this all about?
How the industry is responding
2012 Outlook: May You Live in
Interesting Times
 Market share is redefined and with it, intensified battles.
 Tiered/narrowed networks move markets overnight.
 Redesigned benefits = more bad debt
 Cost cutting yields to margin management.
 Patients expect Apple at Dollar General prices.
 IT implementation breaks the bank and drives alliances.
 New market entrants and technology enablement
threaten incumbent dominance.
 Policy, politics, budgets keep the C-suite up at night.
IT = information technology.
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3
At the Heart of Health Care Reform…
Efficiency
Quality and Safety
Well-Defined Care Paths
Provider Error
Less Costly Sites of
Care
Value
70%
Waste
30%
Coordinated Care
Unnecessary Care
Readmissions
Avoidable Conditions
Increased Access
Lack of Care
Coordination
Predictive Care Paths
“Estimates suggest that as much as $700 billion a year in health
care costs do not improve health outcomes.”
–Peter Orszag, Former Director of the Congressional Budget Office
Source: Inskeep S. Budget chief: for health care, more is not better. National Public Radio.
www.npr.org/templates/transcript/transcript.php?storyId=103153156. Published April 2009 on
Morning Edition. Accessed June 2011.
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Health Care Reform Accelerates the
Need for Proving Performance
Medicare Shared
Savings Program
Payment pilot
programs
Medicare readmission penalties
Hospital VBP Program
PPACA
passes
2008
2010
Payment adjustment
for HACs
2012
2014
2016
The Middle Game
 Health care reform highlights tension between increased access and cost control.
 Payers are piloting new models that reward coordination, quality and efficiency.
 Evidence-based multidisciplinary care that spans the care continuum is a required
competency for programs.
 Clinical practice research continues to uncover opportunities to improve care.
 Focus on decreasing inpatient costs continues as hospitals try to control staffing,
length of stay (LOS) and device costs.
HAC = hospital-acquired condition; VBP = value-based purchasing; PPACA = Patient Protection and
Affordable Care Act.
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While Growth Across the IP Business
Is Flat, OP Opportunities Abound
Adult Inpatient Forecast
US Market, 2012−2022
Millions
40
5 Year
10 Year
+18%
35
Adult Outpatient Forecast
US Market, 2012−2022
Billions
5 Year
4.5
4.0
+20%
+9%
30
3.5
25
3.0
20
2012
–1%
2017
Sg2 IP Forecast
–4%
2022
10 Year
+28%
+15%
+7%
2.5
2012
Population-Based Forecast
2017
Sg2 OP Forecast
Note: Forecast excludes ages 0–17, psychiatry and obstetrics service lines and the not assigned category.
Sources: Impact of Change® v12.0; NIS; Pharmetrics; CMS; Sg2 Analysis, 2012.
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2022
What Does This Mean for a Typical
Health System?
 Focused on inpatient business
 Strong physician referral channel
 ED as the “front door” for majority
of admissions
 Excels at revenue cycle, LOS
management
 Few System of CARE linkages
 Lots of inappropriate utilization and
readmissions
 CFO pushed 5% cost reduction
over the past 3 years
ED = emergency department; LOS = length of stay; CARE = Clinical Alignment and Resource Effectiveness.
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Fast Forward 5 Years
2011
2016
 Hospital is a success!
 Hospital is growing and
profitable.
 Physicians are happy.
 System wins best
employer award.
 Weaker aspects of
performance do not
affect market or
financial results.
CMS = Centers for Medicare & Medicaid Services; PCP = primary care physician;
PAA = potentially avoidable admission.
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 CMS docks hospital
5% of revenues for
PAAs, readmissions.
 Hospital is excluded
from private payers’
preferred tier networks.
 Patients shop to
manage their out-ofpocket liability.
 PCPs redirect cases
away to maximize their
incentives/reduce
penalty exposure.
 Profitability and market
share erode.
Start By Asking New Questions
Standard Thinking
Value-Driven Thinking
Grab share at all
costs.
How do I drive
sustainable margin?
What is our
product?
Readmits are
revenue.
Worry later.
How do we perform?
What is our value
proposition?
How do I optimize
payer rates?
Any volume is
good.
How can I backfill as
readmissions drop?
MD? Has a
pulse? Buy!
How do we survive
new payment models?
The economy is
getting better.
Volumes will
rebound
Confidential and Proprietary © 2011 Sg2
How do we capture
the System of CARE?
9
What is
appropriate future
demand?
What is market
share?
What MDs do we
want?
Who are my real
competitors?
Future Payment Models Seek to Reward
Coordinated, Quality Care
Confidential and Proprietary © 2011 Sg2
Out-of-Pocket
ACOs
Medical Home Model
Bundled Payment
CMMI Initiatives
Emerging Payment and Care Delivery Models
10
Objectives
 Decrease premiums and
slow spending growth
 Reduce spending variation
 Improve quality
 Find efficiency
 Improve care coordination
What New Economic Structures Will
Enable Us to Redesign the Work?
High
Degree of Complexity
Global capitation
ACO
Clinical integration program
Disease-specific capitation
Bundled episodes (pre- and post-care included)
Bundled episodes (inpatient only)
P4P/Value-based purchasing
Inpatient case rates (DRGs)
Fee for service
Low
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Scope of Risk
11
High
Providers Will Be Asked to Be More
Accountable and Take on More “Risk”…
What is the cost per patient to manage back pain?
How many
people have
back pain?
Cost =
Person
Service
# Conditions
Person
Conservative
management
vs. surgical
intervention
How many
acute
episodes do
they have?
×
# Episodes
Condition
×
Expensive
implant or
less-costly
implant
# Services ×
Episode
Performance Risk
Actuarial Risk
Source: Network for Regional Healthcare Improvement. From Volume to Value: Transforming Health Care
Payment and Delivery Systems to Improve Quality and Reduce Costs. November 17, 2008. Available at
Robert Wood Johnson Foundation Web site. www.rwjf.org/newsroom/product.jsp?id=36217. Accessed
October 2010.
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Cost
The Private Market Will Lead Innovation
CalPERS Pilot,
Northern CA:
40,000 members,
well-managed IPA
Tucson
Medical
Center,
Tucson, AZ:
50 to 60 PCPs
Advocate Health
Care, BCBS,
Chicago, IL:
CI program evolved
into ACO.
Norton,
Louisville, KY:
Partnership with
Humana
Carilion Clinic,
Roanoke, VA:
17,000 employees
beginning July 1,
leading to
cobranded
insurance product
Piedmont Physicians
Group, Atlanta, GA:
100 physicians, about
10,000 CIGNA members
CalPERS = California Public Employees’ Retirement System; BCBS = Blue Cross and Blue Shield; IPA = independent
practice association; CI = clinical integration; PCP = primary care physician. Source: Sg2 Interviews, 2011.
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Case Example: CalPERS ACO Pilot in
Sacramento
CalPERS Pilot (Northern CA)
 Catholic Healthcare West, Hill Physicians,
Blue Shield (CA)
 42,000 lives
 “Virtual cooperation” model
http://www.worldatlas.com/webimage/countrys/nam
erica/usstates/counties/ca.htm
Initial
Critical
Success
Factors





Experienced physician participants
3-way risk sharing and ongoing collaboration
Upside for all participants
“Teach back” program and daily rounds
Public validation from payer
Source: Sg2 Interview With CalPERS Pilot, July 2010.
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Year 1: Significant Savings…Mostly Due
to Reduced Hospital Utilization





Exceeded target of $15.5 M in savings for the 42,000 member pilot
15% reduction in inpatient readmissions
15% reduction in average length of stay for inpatient admissions
14% reduction in inpatient days per thousand
50% reduction in inpatient stays per thousand of 20 or more days
“2010 was the easiest year that we’re going to have.
After that, it will require real hardcore process reengineering to be successful.”
- Rosaleen Derington, Chief Medical Services Officer,
Hill Physicians Medical Group
Source: “A Community Model Case Study”, presented by Juan Davila and Rosaleen Derington at the
America’s Health Insurance Plans Summit on Shared Accountability, Washington DC, October 2011.
Confidential and Proprietary © 2011 Sg2
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Considerations in Defining the Right
Timing for Your Strategy Evolution
Slower
Faster
Organizational Issues
ED-driven inpatient strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . Diversified System of CARE strategy
Limited IT infrastructure . . . . . . . . . . . . . . . . . . . . .
Well-integrated and pervasive EMR
Market Issues
Highly fragmented splitter market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Regionally consolidated
Dominant, conservative payers . . . . . . . . . . . . . . . . . . . . . . . . Competitive and/or innovative payers
Regulatory Issues
Game-changer 2012 election . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stay-the-course election
Restrictive insurance exchange . . . . . . . . . . . . . . . . . . . . . . . . Flexible state regulatory environment
System of CARE Issues
Constrained, fragmented sub-acute capacity . . . . . . . . . . . . . . . . Robust System of CARE capacity
Poor integration, effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . Strong integration and relationships
Confidential and Proprietary © 2011 Sg2
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Agenda
What is this all about?
How the industry is responding
In the Short-term, Focus on Protocols,
Coordination, Prevention
Top Strategies to Improve Quality, According to Health Plan Leaders
Score (Scale of 1–5)
Better Treatment Guidelines and Protocols
EHR and e-prescribing
Care Coordination Teams
Communication Among Physicians and Hospital
Preventive Care and Patient Education
Decision Support Tools
Pay for Performance
Comparative Effectiveness
Medical Home
Remote Patient Monitoring
ACOs
Transparency/Public Reporting
Employing Physicians
3
3.5
4
EHR = electronic health record. Sources: HealthLeaders Media Intelligence. Industry Survey: Health Plan
Leaders. HealthLeaders Media, 2011; Sg2 Analysis, 2011.
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4.5
Care Redesign Will Offer a Framework
to Help Execute on Value-Driven Strategy
Value (Quality/Cost)
Elements of Care Redesign
System
Optimization
Clinical
Restructuring
Unnecessary
Care Reduction
Variance
and Cost
Reduction
Execution Risk
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The Tried and True: Variance and Cost
Reduction
Value
Variance and Cost Reduction:
Improving operational efficiencies
Risk
Sample Analytics
Potential Hurdles
 Margin mix
 Labor effectiveness
 Supply cost analysis
 Physician resistance
 Inadequate data capabilities
 Existing vendor relationships
Examples
 Minimizing orthopedics supply chain costs
 Decreasing turnaround time for chemotherapy chairs
 Standardizing clinical pathways for asthma patients in the ED
 Uncovering staffing and productivity opportunities
ED = emergency department.
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Reduce Variation in Rehabilitation
Across Post-Acute Care Sites
Sample Hospital TJR Rehab Cost per Patient, 2007–2009
$9,000
Home Health
$8,000
HH & OP PT
$7,000
OP PT
$6,000
SNF
$5,000
$4,000
$3,000
$2,000
$1,000
$0
5
10
15
20
25
Duration (Weeks)
Note: Postdischarge claims were filed after the date of discharge. Excludes episodes with cost >$46,000.
TJR = total joint replacement; HH = home health; OP = outpatient; PT = physical therapy.
Source: Sg2 Analysis, 2011.
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Improve Access and Productivity
Through Centralized Scheduling
WellSpan Health System, York, PA
 Centralized call center was
implemented to address patient
and staff satisfaction.
 40 employees, 3 supervisors work
shifts 7 am–8 pm weekdays and
8 am–4 pm Saturdays.
 Goal is to answer 80% of calls within
20 seconds.
 One practice increased the number of
visits from 1.9 to 2.1 per hour.
 Noise reduction in practices also is
increasing employee efficiency.
Source: Sg2 Interview, 2011.
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Value
Prepare for Penalties and Tiered
Networks by Reducing Unnecessary Care
Risk
Unnecessary Care Reduction:
Decreasing avoidable, unproductive and
duplicative services
Sample Analytics
 Evidence-based clinical
criteria
 Readmission analysis
Potential Hurdles
 Lack of care coordination between providers
 Weak relationships with post-acute providers
 Slow development and diffusion of clinical
effectiveness research
Examples
 Daily blood draws on inpatients
 Readmissions for CHF patients discharged to SNFs
 Excessive or duplicative imaging studies between sites of care
 Prostate cancer screenings for elderly patients
SNF = skilled nursing facility.
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Standardize Radiology Ordering Process
to Improve Diagnostic Utility
Institute for Clinical Systems Improvement, Bloomington, MN
Innovation: Standardized Orders
 Designed a clinical decision support system that grades
the tests being ordered based on information and purpose
 Decision support system approved by ACR, ACC and ACP.
 System offers evidence-based alternatives.
 Piloted by 5 medical groups completing more than 1 million
imaging tests per year between 2007 and 2010
Results




Shorter radiology ordering and approval times
10% improvement in diagnostic utility
Estimated savings of $84M
No increase in claims for imaging
ACR = American College of Radiology; ACC = American College of Cardiology; ACP = American College of Physicians;
M = million. Sources: Institute for Clinical Systems Improvement (ICSI). ICSI News November 3, 2010. Accessed June
2011; Sg2 Expert Insight: Transforming How Radiology Studies Are Ordered in Minnesota, February 2, 2011.
Confidential and Proprietary © 2011 Sg2
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Accelerate Access for Unscheduled
Visits
Sutter Medical Foundation—Sutter Health, Sacramento, CA




Operates 3 urgent care centers; 4 more are planned.
Integrated with retail care, occupational health and diagnostic centers
Future plans to collaborate with FQHCs to manage new Medicaid enrollees
Fast-track access for 10 diagnoses.
ED = emergency department; UTI = urinary tract infection; IV = intravenous; FQHC = Federally Qualified Health Center.
Source: Sg2 Analysis, 2011.
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Value
Encourage level of Care Optimization
Through Clinical Restructuring
Risk
Clinical Restructuring:
Ensuring treatment occurs in the optimal
setting with the most appropriate provider level
Sample Analytics
 Site/level of care cost
 Capacity and access
modeling
Potential Hurdles




Current regulations and benefit coverage limits
Lack of human capital planning
Physician resistance
Poor access to primary care providers (PCPs)
Examples




Early transfer from an IP to SNF bed
Pharmacists managing all medications for patients with chronic diseases
Partnerships with a local retail clinic to offer nonurgent, convenient care
Palliative care/end of life in ICU/ED
IP = inpatient; ICU = intensive care unit.
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Improve Quality of Care While Managing
Costs
California Pacific Medical
Center, San Francisco, CA
University of California,
San Francisco
 $2.2 million in annual savings
and improved clinical
outcomes:
 $2,179 savings for patients who
received palliative care (PC)
services
 33% decrease in mean daily
costs
 30% decrease in mean LOS
 14.5% lower costs when
compared to usual care patients
 86% decrease in pain scores
 64% decrease in dyspnea
scores
 87% decrease in secretion
scores
With
PC
Savings
Pharmacy
$793
$31
$762
Laboratory
$138
$7
$131
Radiology
$57
$2
$55
Room
$837
$412
$425
Services
$616
$16
$600
Supplies
$230
$24
$206
Total Costs
$2,671
$492
$2,179
Costs
Source: California HealthCare Foundation, February 2010.
Confidential and Proprietary © 2011 Sg2
Without
PC
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Use OP Palliative Care to Reduce
Utilization While Improving Outcomes
Everett Clinic, Everett, WA
Background
 Multispecialty practice with 11 locations
Challenge
 High use of hospital services for end-of-life patients
Solution: Outpatient Palliative Care Program
 Patients are referred to palliative program by physicians.
 Program is run by nurses and assistants. Nurse provides ongoing
care management and filters appointments and medications.
 Nurses proactively call all 250 patients once per month.
Results
 47% vs 62% hospital admit rate for patients who received palliative care vs those who did not
 Palliative care patients’ ALOS was 0.5 days fewer than nonpalliative patients.
 Reduced ED care and inpatient care utilization
Selection criteria based on this question posed to physicians:
“Would you be surprised if this patient died in the next 1 to 2 years?”
ALOS = average length of stay. Source: Szabo J. High-quality palliative care programs bring comfort to
terminally ill patients. AHA News September 6, 2010. American Hospital Association.
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Use Telehealth and Home Health
to Redesign Acute Care Delivery
Sentara Healthcare, Northern Virginia
Goals
 Improve compliance, bed capacity and patient satisfaction
 Reduce readmission, LOS and HAC
Innovation: Telehealth and Home Health
 Pilot project to identify and evaluate acute care patients appropriate for early discharge with
enhanced home health and telehealth services
 HF, pneumonia, COPD, SOB, respiratory failure, atrial fibrillation and MI patients qualify.
 Admission criteria meet Medicare homebound criteria: cognitively intact, home electrical and
telephone services.
 Patients are referred by nurse and hospital case manager; discussed with patient and hospitalist.
 Patients seen by home care on day of discharge; telehealth monitoring begins on admission visit.
 PCP notified of patient’s admission to home care for follow-up orders and plan of care.
Results
 Treated 83 patients under pilot project
 Decreased LOS by 0.49 days at one hospital and 1.14 days at a second hospital
 Decreased readmission rates for same diagnoses to 3.6%
SOB = shortness of breath. Source: Sg2 Interviews, 2011.
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Value
Manage Population Risk Through
Integration and Prevention Strategies
Risk
System Optimization: Shifting focus to
upstream, preventive care through clinical
integration and population health management
Sample Analytics
 Population health
analytics
Potential Hurdles
 Lagging incentives for preventive care and care
coordination
 Significant capital investment for a coordinated
shared savings infrastructure
 Poor relationships with PCP networks
Examples
 Disease-based medical homes
 Patient engagement strategies using telehealth
 Disease registries
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Patients Are Coming From Mars,
Physicians Are Leaving for Venus
The Complicated Universe of Ambulatory Care
Your blood pressure
is high, and I am worried
that you cannot walk up
a flight of stairs.
Let’s have you come back
next week to talk about
your knee.
Dr Jones, I’m having
knee pain. I can’t keep up
with my child anymore.
I hope she doesn’t
tell me I am fat.
How could they
schedule this man for a
15-minute visit?
I should schedule him for a
treadmill in case he has silent
ischemia with his diabetes.
My wife is really
unhappy that I
lost my job.
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MDs Challenged With Aligning Patients’
Clinical Needs While Lowering Costs
Care Customization
Simple Visit
Priority
Delivery
Ambulatory
ICU
Social
ICU
Team
MLP
Physician
Physician
MLP
MLP
Social Worker
Nurse
Physician
Nurse
Social Worker
MLP
Physician
Behavioralists
Setting
Office
Office
Multispecialty
practice
Multispecialty
practice
Example
Sprained
ankle
Multiple issues,
pick 1
Serious chronic
condition(s)
Overweight
smoker, uninsured
MLP = midlevel provider.
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Preliminary Results From Boeing
Ambulatory ICU Pilot
Boeing Intensive Outpatient Care Program (IOCP), Puget Sound, WA
 Partnered with 3 clinics, incentivized through per-patient-per-month fee
 Focused on employees contributing to highest health care costs
 Care teams included RN care manager, IOCP physician, current PCP




Patient involved in development of personalized care plan
Care team proactive outreach
Education in disease self-management
Team huddles to assess patient status, discuss follow-up plan
 Improved functional status, depression scores, patient and
provider satisfaction
 Met clinical quality metrics for diabetes care, high blood pressure,
high cholesterol
 Reduced per capita spending by 20%
Source: Milstein A and Kothari P. Are higher-value care models replicable? Health Affairs Blog.
http://healthaffairs.org/blog/2009/10/20/are-higher-value-care-models-replicable. Accessed October 2011.
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Utilization and Behavioral Patterns Help
Identify Social ICU Patients
Jeffrey Brenner, MD, Camden, NJ
 Used medical billing data to explore health
trends:
 1% of Camden’s patients accounted for 30%
of costs
 Identified 2 most expensive blocks: a large
nursing home and a low-income housing tower
 Camden Coalition of Healthcare Providers
formed to provide a medical home for
“super-utilizers”
 Rely on home visits, phone calls, urgent call
number to reach patients
Results
 40% reduction in ED
visits
 56% reduction in
hospital bills
“The people with the highest medical costs—the people cycling in and
out of the hospital—were usually the people receiving the worst care.”
ED = emergency department. Source: Gawande A. The hot spotters. The New Yorker January 24, 2011.
www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande. Accessed June 2011.
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Increase Retention and Improve Patient
Outcomes With Care Coordination
Advocate Health Care, Oak Brook, IL
Background
 12-hospital system, including 2 children’s hospitals and a medical group
Care Coordination: AdvocateCare Program Focused on
5 Aspects to Improve Care
 Enterprise care management
 Enhance ED case management and OP care coordination
 Improved access
 Expand PCP/clinic hours
 Build retail clinic relationship
 Market share
Advocate…“could serve as a model for a
 Target splitter docs and unassigned
new kind of accountable care organization,
patients in the ED
by demonstrating how to organize
 Data analytics
physicians into partnerships with hospitals
 OP care management system
to improve care, cut costs and be held
 Prospective risk analysis
accountable for the results.”
 Post-acute care providers
–Health Affairs January 2011
 Preferred networks of providers
 Transition coaches
Source: Shields MC et al. Health Aff (Millwood) 2011;30:161–172.
 SNF management with “SNFists”
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Extend Outreach to Capture
Downstream Revenue
Direct Mail
Phone Calls
Web Presence
Printed with permission of ThedaCare.
Printed with permission of ThedaCare.
ThedaCare, Appleton, WI
Results During 2.5-Month Campaign
 10% of targeted patients scheduled and completed a colonoscopy.
 28% increase in the average number of colonoscopies performed.
 ThedaCare is preparing to roll program out to other clinics and service areas.
Overall Increase in Screening Rate
 21% increase to 73% between 2005 and 2010 (also due to disease management efforts)
Source: Sg2 Interview, 2011.
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Where is the Venture Capital Going
 CareHubs (Beaverton, OR) is a healthcare enterprise social platform that offers
dynamic, innovative tools to help patients and healthcare providers better connect,
coordinate and engage.
 CareWire (Minneapolis, MN) is a patient engagement solution that utilizes automated
patient text messaging to increase billable appointment yield, visualize patient
satisfaction in near-real-time and improve provider performance.
 DermLink (Atherton, CA) is a cloud-based, HIPAA compliant application that enables
remote diagnosis of dermatology cases, dramatically reducing wait times for patients
while driving increased revenue and flexibility for providers.
 Iconic Data (Norcross, GA) delivers a cloud-based patient list manager solution that
provides physicians access to near-real-time snapshots of clinical care episodes across
disparate, non-integrated facilities, resulting in increased charge capture and reduced
inefficiencies.
 UnitedPreference (Princeton, NJ) offers a Tailored Spend™ payments network that
improves member participation in preventative health initiatives via nationally accepted
prepaid cards that can only be used to purchase goods and services pre-determined by
health plans and employers.
Sample Of HealthBox 2012 Class
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Successful Strategy Requires
Management and Engagement
Care Managers
Pt. Profiling
Acuity
Hospital
Community-Based
Care
Retail
Pharmacy
Information
Systems
Ambulatory
Procedure
Center
IP Rehab
Data Analytics
Physician
Clinics
SNF
Preventive
Care
Home
Acute
Care
Wellness and
Fitness Center
Diagnostic/
Imaging
Center
Technology
Urgent
Care
Center
Post-Acute
Care
Home
Care
Disease Mgmt
CARE = Clinical Alignment and Resource Effectiveness; IP = inpatient; OP = outpatient; SNF = skilled nursing facility.
Confidential and Proprietary © 2011 Sg2
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OP
Rehab
Sg2 provides business analytics for health care.
Our data-driven systems, business intelligence and
educational programs deliver growth and performance
improvement solutions across the care continuum.
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