Partners Approach to Meeting the
Healthcare Cost Challenge
Timothy Ferris, MD, MPH
SVP, Population Health Management, MGH, MGPO and Partners
HealthCare
Nuffield Trust Health Policy Summit 2014
March 6, 2014
Division of Population Health Management
What we’re facing…
 Constraining the growth of healthcare costs is a national priority
 Involvement of physicians through changed incentives is unavoidable
 PPACA - the imperative will persist even if the specifics change
 The market is using a similar play book – closed networks,
budget-based risk, cost sharing, restriction of choice – and this
may generate the same backlash as 1990s managed care era
 But...
 The economy is much worse
 Government is proactive (3.6%)
 Rate of change is slower (caps on increases, not cuts)
 And we have…
 Better health IT and data for population management
 Strategies and tactics that we know will improve care and reduce costs
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Division of Population Health Management
Implications for providers
 Our focus should be on reducing medical expense trend to as
close to the rate of general inflation as we can
 We want to be part of the solution
 This means taking financial risk for costs of care
 Shared savings (Pioneer ACO), bundled payments, global payments
 Partners increased ability to care for populations of patients
 Successful CMS Demo, increasing evidence for other tactics
 Universally adopted EHR
 Challenges
1. We need tactics that will be successful under any new payment model
2. How to make external incentives meaningful to our physicians
3. Moving at the right pace
 Too fast: we will lose the docs in the rush to implement – MDs attitude
often creates the patient's attitude (managed care backlash)
 Too slow: will mean not succeeding under the contracts and worsening
the regulatory environment
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Division of Population Health Management
What is an ACO?

An organization that agrees to share the financial risk for the care of a
defined population
 Shared financial risk =
rewarding providers for
reducing medical spending
by giving them a share of the
net cost savings; may also
include financial penalties for
cost increasing above
benchmark
Total Accountable Care Organizations by
Sponsoring Entity
Total = 606
 Defined population = every
primary care patient whose
insurer has signed a risk
contract with that provider,
regardless of where they
receive care
Source: Leavitt Partners Center for Accountable Care Intelligence at
http://healthaffairs.org/blog/2014/01/29/accountable-care-growth-in-2014-a-look-ahead/
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Division of Population Health Management
Evolution of ACOs
Estimated Accountable Care Lives in Public
and Private ACOs*
18.2m covered lives compared
to 13.6m at end of 2012
•More than half of the US population (52%)
live in primary care service areas served
by ACOs, approximately 28% live in areas
served by 2 or more ACOs.**
•Los Angeles, Boston, and Orlando, have
the most ACOs in the nation.* In Boston,
ACOs care for more than 60% of
patients.***
Accountable Care Organizations by State*
*Leavitt Partners Center for Accountable Care Intelligence at
http://healthaffairs.org/blog/2014/01/29/accountable-care-growth-in-2014-a-look-ahead/
**http://www.oliverwyman.com/media/ACO_press_release(2).pdf
***http://www.acpinternist.org/archives/2013/07/acos.htm
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Division of Population Health Management
Background on Partners HealthCare
 Partners HealthCare (Partners)
 Integrated delivery system in Boston MA, includes two
AMCs
 Massachusetts Hospital (MGH)
 Brigham Women’s Hospital (BWH)
 Partners became a Pioneer ACO, January 2012
 Includes community and specialty hospitals, a physician
network, home health and long-term care services, and
other health-related entities
 615 PCPs
 76,000 patients
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Division of Population Health Management
The path we’re traveling at Partners
Pressure to reduce
cost trend
New contracts with
risk for trend
Investment in Population
Management Infrastructure
1
2
Partners in Care (PCMH & care
coordination for high risk patients)
Changes to Partners
org structure
Internal Performance
Framework
3
Implement new local
incentives/compensation
Network Affiliations
4
New relationships with
community hospitals and
doctors
Enhanced access to specialty
services
Sustained cost trends near GDP
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Division of Population Health Management
Our new contracts…almost 2 years in
Lives under the Accountable Care Model
1
Medicare
Pioneer Accountable
Care Organization
Elderly population,
care management
central to trend
management
Covered lives: ~75k
2
Commercial
Alternative Quality
Contract (AQC)
Younger population,
specialists critical to
management
Covered lives: ~350K
3
Medicaid
NHP
Population with
significant disability,
mental health, and
substance abuse
challenges
Covered lives: ~25K
4
Self Insured
Partners Plus
Commercial
population, but
savings accrue
directly to Partners,
and improves our
own lives
Covered lives: ~80k
Partners currently manages roughly 500,000 lives in various accountable care relationships
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Division of Population Health Management
Priority programs
Priority Population Health Management Programs
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Primary Care
•Patient Centered Medical Home (PCMH), including especially
access
•High risk care management
•Mental health
Specialty Care
•Referral management
•Virtual visits
•PrOE/PROMs
•Bundles
Care Continuum
•SNF networks
•Mobile observation units
•Urgent care
Patient Engagement
•Shared decision making
•Virtual patient communities
•Customized risk and educational materials
Infrastructure
•IS, analytics
•Program management
Division of Population Health Management
Virtual visits and technology tools
Pediatric Virtual Video Pilots
Technology
•Follow up visits in the home for children and adolescents with
Autism, ADHD, Substance Abuse, etc,
Email
•Post-acute burn consults for patients at Boston-Spaulding
Rehabilitation Hospital
Video
Conferencing
•Parents of patients in the PICU virtually attend rounds with care
team and their child
35
48
Pediatrics
Burns Center
Telephone
100%
2
60%
40%
Electronic
Curbside
Resulted in Visit
17
20%
0%
Cardiology
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Division of Population Health Management
*Start of pilot Jan 2014
Child and Adolescent
Psychiatry
Cardiology Curbside Consults*
80%
Text
Messaging
313
Curbside Consult
Performed
•Referring physicians can quickly contact a
cardiologist in the outpatient setting and
receive recommendations in the electronic
medical record
•Offers referring providers and patients an
alternative to waiting for in-person cardiology
appointments
Approaches for managing referrals
Chen, A. H., Kushel, M. B., Grumbach, K., & Yee, H.F. (2010). Practice profile:.A safety-net
system gains efficiencies through ‘eReferrals’ to specialists. Health Affairs (Millwood), 29(5),
969-71.

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Why is this important?
 Assessing the appropriateness of referrals prior to scheduling may have
a positive impact on our efforts to
 Reduce avoidable office visits
 Increase access for our sickest patients
 Increase experience coordination and efficiency of specialist visits
through pre-visit planning
Division of Population Health Management
Idealized patient journey through an episode of
care that includes a procedure
Assess
Shared Personalized
Appropriateness
Decision Consent
Criteria
Assess Making Form
Patient
Risk
Problem
Physician
encounter
Tier 1, 2
Outcome
Measures
Tier 3
Outcome
Measures
Schedule
PreProcedure Recovery
Informed OR
Procedure
Consent
Testing
Possible
Need for
Procedure
Outcome measures hierarchy:
Tier
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Category
Examples
1
Health status achieved
Survival and degree of health recovery
2
Process of recovery
Time to recovery and return to normal
activities
3
Sustainability of health
Sustained recovery and recurrences,
including long term consequences of
therapy
Division of Population Health Management
PrOE: Inputs and outputs
INPUTS
OUTPUTS
PrOE Appropriateness tool
Appropriateness
Indications & Decision
support
Prepopulated
data fields
(NLP
search)
LMR, OnCall
EMR
EHR note
created
RPM,
RPDR,
CDR,
EMPI
PCI, CABG,
Vascular,
Harris Joint
Appropriateness
Data Repository
Data
storage
Existing
registries
Division of Population Health Management
Internal
Performance
Dashboards
Public
Reporting
Billing and
Prior
Authorization
Copy of
appropriateness
results placed in
LMR and CDR
Data passback to
registries (Web
service)
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Procedure
Scheduling
Measurement & analysis of
appropriateness and
outcomes inform guidelines
and indications in real-time
Personalized
consent
form
Results to date
Percent of Procedures with a PrOE Assessment
2014 Procedures
100%
•Incisional Hernia
•Prostate Biopsy
•Gastric Bypass
•Valve Repair
•Lumbar Fusion
•Peripheral Vascular Disease Therapies
90%
80%
70%
60%
50%
Not in PrOE
40%
In PrOE
30%
20%
10%
0%
CAS
CEA
CABG
Diagnostic
Catheterization
Appropriateness Scores for Diagnostic
Catheterization at MGH vs. NY Cardiac Database **
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Median hospital-level
inappropriateness rate is
28.5%**
90%
Median hospital-level
inappropriateness rate is
28.5%**
80%
70%
60%
50%
Rarely
Appropriate
40%
Maybe
Appropriate
20%
Maybe Appropriate
10%
Appropriate
Appropriate
0%
Rarely Appropriate
30%
Aug
MGH
n=745
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100%
Appropriateness Scores for Diagnostic
Catheterization by Month
NY Cardiac
Database
n=8986
Division of Population Health Management
Sept
Oct
Nov
Dec
**Hannan, EL, et al. Appropriateness of Diagnostic Catheterization for Suspected Coronary Artery Disease in
New York State. CIRC INTERVENTIONS. January 28, 2014. 113.000741
Patient Reported Outcome Measures (PROMs)

Outcomes that matter to patients: direct collection of information from
patients regarding symptoms, functional status, and mental health.

Why PROMs?



How are PROMs collected?


Patients enter information into an electronic platform using
iPads, patient portal, or the web
PROMs will be implemented for all sites and
diagnoses

Current Conditions include:






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Improves care of individual patients through better
monitoring and improved responsiveness
Improves system-wide care by measuring/improving the right
outcomes – those that matter most to patients
Coronary Artery Disease: CABG, Cardiac Catheterization
Osteoarthritis
Valvular Disease
Diabetes
Depression
Additional conditions planned for 2014
Division of Population Health Management
What does PHM cost?
PHM Cost as a Percentage of External Risk TME
(At 2017 Steady State Run Rate)
Total Costs as Percentage of External Risk
TME only
PHM Program Costs as a Percentage of
External Risk TME only
4.96%
4.96%
Total Cost
PHM Programs
(Annual
Operating & 1x
expense)
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Division of Population Health Management
What is the ROI?
$250
PHM Program Savings Relative to Total Operating Program Costs
(Assumes Steady State in 2017)
$200
$150
$100
$50
$0
2015
2016
•Two-thirds of PHM acceleration costs fund programs that generate TME savings
•Remaining funds support infrastructure, innovative pilots (i.e. SNFist),
community specialist engagement that accrue minimal or difficult-to-measure
savings
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Division of Population Health Management
2017
Total PHM Acceleration Cost
Savings from External Risk
Savings from full IPF
Savings from full panel (Loyalty Cohort)
Key Challenges

Overlapping programs and contracts (e.g. Chronic Disease Demo)

Timely data and useful performance measures (CMS delays with delivery of
prospective patient information)

Transition costs—establishing the EHR infrastructure

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Funding the infrastructure (no grant funds)

Intersection between the multiple Boston area ACOs
 Notification management
 ED notification
 Discharge notification
 Sharing of best practices between colleagues

Learning what works and providing timely feedback for policy
changes/enforcements to CMS

Limited leverage when patients seek covered services that provide little or no
benefit

Time to ROI not consistent with duration of contracts
Division of Population Health Management