Doing Care Differently:
The Journey to a Healthier Kentucky
Innovate, Accelerate, Collaborate
2014 Howard L. Bost Memorial Health Policy Forum
September 16, 2013
“Health is a state of complete physical, mental and
social well-being and not merely the
absence of disease or infirmity.”
Health Impact Pyramid (CDC)
Factors that Affect Health
Source: Georgia Department of Public Health; Centers for Disease Control and Prevention
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The Institute for Healthcare Improvement (IHI)
The Triple Aim
U.S. health care system is the most
costly in the world
Population Health
Yet, we get the worst outcomes of nearly
any industrialized country, even when
adjusting for age and income
And, Kentucky is among the lowest U.S.
states for outcomes, according to the
America’s Health Rankings
Experience of Care
Per Capita Cost
Source: Georgia Department of Public Health
http://www.ihi.org/Engage/Initiatives/TripleAim/pages/default.aspx
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The Healthcare Landscape
Perspectives: Healthcare is a different industry than it used to be
“I don’t blame anybody – they’re just
doing what makes sense and we have
to change what makes sense.”
Don Berwick – Former CMS Administrator
“Digital Health feels like the PC industry
in the early ’80′s.”
John Sculley – Former Apple and PepsiCo CEO
“I think the extreme complexity of
medicine has become more than an
individual clinician can handle. But not
more than teams of clinicians can
handle.”
Atul Gawande – Surgeon, Author, Journalist
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The Healthcare Landscape
The Market Is Complex And Evolving
The U.S. health market requires greater flexibility and insight than ever before. Leaders increasingly
need expert advice to make sound decisions in today’s climate.
Aging
Population
Quest for
Value
Evolving
Payment Models
Emerging
Technologies
Unprecedented
Environmental
Change
Comparative
Transparency
Consumerism
Regulatory
Environment
State Budget
Crises
Workforce
Challenges
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The Healthcare Landscape
Drivers and Enablers of Change
Various economic, technological, regulatory and social factors are pushing the industry in new
directions, creating problems that never before existed.
Demographics
Key Drivers
Population Growth
Population Ageing
Chronic Conditions
Convergence
Business
Model
Enablers
Payer-Provider
Integration
Incentive Alignment
Risk Shifting
‘Big Data’
Technological
Enablers
Aggregation, Storage and
Analytics
Pooling/Open Data
Data Center Capacity
Economic Pressure
Governments
Employers
Market Competition
Consumerism
Consumer Engagement
Value Based Benefits
Wellness/Preventative
Programs
Mobility
Telemedicine
Wireless Sensors
Remote Patient Monitoring
Apps/Social Media
Healthcare Reform
PPACA (US)
Other global reform (e.g.,
GER)
ARRA, HITECH for EHR
Care Model Redesign
Population Models (e.g.,
PCMHs, ACOs)
Condition Oriented Models
(COEs, DM programs)
Personalized Medicine
Genomics
Targeted Therapeutics
Personalized Treatments
Pharma Firms Competing
to ‘Own The Disease’
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The Healthcare Landscape
Where is the industry going?
Healthcare transformation has afforded physicians unprecedented opportunities to shop their
medical degrees to firms tasked with solving today’s issues.
The Past
The Future
Providers, patients
Risk Employers, payers
Reimbursement Service/volume-based
Performance/value-based
Information Siloed, static, paper-based
Networked, dynamic, digitally-based
Treatment One-size-fits-all, volume-based
Personalized, value-based
Delivery Hospital-based, expert/specialist driven
2000
2005
Community/retail-based, team driven
2010
2015
2020
Physicians are in the unique position to help shape the industry’s future.
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Healthcare Reform
Health care organizations should take offensive and defensive strategic responses to these drivers:
ISSUES
High cost to families
■ Average insurance $14,000/
family and has doubled in last
9 years
■ Aging population with more
health problems
High Cost To Federal Government
■ Fastest growing segment of
federal budget
Holes in coverage
People who need insurance most
often turned down by preexisting
conditions, lifetime limits, small
business costs
1 in 7 had no insurance or under
insured
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Healthcare Reform
Health care organizations should take offensive and defensive strategic responses to these drivers:
ISSUES
SOLUTIONS
Insurance Reforms (no lifetime
limits, limit preexisting
conditions)
Adjustments to Government
programs (Medicaid expansion,
Medicare Drug program)
Health Insurance marketplace /
exchanges (more competition)
Insurance Mandate - required
insurance coverage (32 million
new insured people)
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Healthcare Reform
Health care organizations should take offensive and defensive strategic responses to these drivers:
ISSUES
SOLUTIONS
IMPACT
$200 Billion savings over 10
years (2% of Budget and 3% of
overall Healthcare spending)
DON’T IMPACT DEFICIT. Must
be paid from savings from
Healthcare Providers, Medicare
Insurers with less
reimbursement and new taxes
on healthcare companies and
individuals
$124 Billion in potential
additional savings over 10
years
In 2012 U.S. health care spending increased 3.7
percent to reach $2.8 trillion, or $8,915 per person
Source: http://obamacarefacts.com/costof-obamacare.php
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Healthcare Reform
Health care organizations need to take offensive and defensive strategic responses to these drivers.
Healthcare
Plans
2011:
2012:
Minimum
Medicare
medical loss ratio Advantage STAR
and rebates
Quality-based
payments
2013:
Administrative
simplification
2014:
Exchanges open
to individuals and
small employers
2017:
Exchanges open
for large
employers
Quality reporting
•
Pay for performance
•
Regulatory influence
•
Transparency/data sharing
Fall 2011:
CMS ACO
application
period
Healthcare
Providers
2012:
CMS ACOs begin
Value-based
incentives and
avoidable
readmission
penalties
2013:
Episode-based
payment pilots
begin
New Sustainable
Business Model
2015:
HITECH
penalties begin
Federally mandated programs that focus on quality and patient safety
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The Healthcare Journey
Are we on diverging or converging paths?
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Innovate
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Heath System Transformation
Overview
Coordinated Seamless
Healthcare System 2.0
--Outcome Accountable
Care
Acute Care System 1.0
--Episodic Non-Integrated
Care




Episodic health care
Lack integrated care networks
Lack quality and cost performance
transparency
Poorly coordinate chronic care
management






Patient/person centered
Transparent cost and quality
performance
Accountable provider networks
designed around the patient
Shared financial risk
HIT integrated
Focus on care management and
preventive care
Community Integrated
Healthcare System 3.0
--Community Integrated
Healthcare







Source: Neal Halfon, UCLA Center for Healthier Children, Families & Communities
Healthy population centered
Population health focused strategies
Integrated networks linked to
community resources capable of
addressing psycho social/ economic
needs
Population-based reimbursement
Learning organization capable of
rapid deployment of best practices
Community health integrated
E-health and telehealth capable
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New Business Models
Patient Protection and Affordable
Care Act of 2010
encourages providers to take responsibility
for the cost and quality of care and enables
the formation of ACOs.
Accountable Care Organization
Shared-Savings Program
Clinically Integrated Network
Centers for Medicare and Medicaid Services
(CMS) created shared-savings program for
accountable care organizations (ACOs)
Other
ACOs
Groups of hospitals and doctors committed
to reducing the cost and improving the
quality of care
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New Business Models
Accountable Care
Organization (ACO)
Value-Based Care
(VBC)
The ACO is the centerpiece
of a Clinically-Integrated
Network Model
Quality Over Quantity
(Value over Volume)
Care Coordination
Assuming increased
financial and clinical
accountability
Level 1 - In Patient Acute Care
Level 2 - Post Acute Care
Level 3 - Chronic Condition Management
Level 4 - Population Health Management
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Big Data, Big Impact
Traditional data management no longer works.
Volume (expanding exponentially)
 social media, household appliances, automobiles, stop lights
 blood pressure cuffs, smart scales, diabetes monitor, exercise equipment
Velocity (rate at which volume is being generated)
 From the beginning of time to 2003, we produced 5 exabytes (10006) of data.
 From 2003 to 2012 we produced 2.7 zettabytes (10007), or 500x more data.
 From 2012 to 2015 we will produce three times more data than between 2003
and 2012.
Variety (types of data being produced)
 documents, data (stock ticker), photos, audio, video, 3D models, location data,
unstructured data
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Is Big Data Worth The Effort?
$300 billion potential impact in exploiting Big Data in healthcare*
The volume and quantity of data needed to
analyze population health in hospitals and
health systems has not existed historically
in healthcare.
Healthcare organizations have not invested
in data and statistical analysis-based
competencies
• Data quantity, prediction, data analysis
population sets, statistics, insurance
actuaries, etc.
Data Driven, John Morrissey, Hospitals & Health Networks, 2013
*McKinsey Global institute
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Improving Healthcare Through Enhanced Technology
Clinical Data Capture
& Analytics
•
•
•
•
•
•
•
•
Data Repository
Claims Data Handling
Terminology Mapping
Physician Scorecarding
Existing Quality
Measures
External
Benchmarking
EMR Interfaces
Clinical Data Handling
Population Risk
Stratification/ Management
•
•
•
•
Predictive Risk Models
Care Gap Reporting
Customizable Filters
Performance
Reporting
• Provider Dashboards
Care Management/
Coordination
• Patient Registries
• Care Gap Reporting/
Alerts
• Visit Planner/Patient
Summary
• Care Transitions &
Coordination
• Clinical Decision
Support
• EMR Integration
Patient
Engagement/ Outreach
•
•
•
•
•
•
•
Patient Portal
Patient Education
Mobile Applications
Automated Reminders
Response Tracking
Patient Assessments
Wellness Programs
= At-Risk Population Management – Risk Stratification Requirement (Timing TBD)
= FTC & CLIO Payer Requirement (2014)
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Accelerate
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Comprehensive Quality Improvement
Two Fundamental Optimization Pathways
■ Operational Performance – generally dealing with
status quo acute hospital care and how to cut costs
and improve revenue
■ Clinical Quality – movement towards outpatient
home care, clinical outcomes, patient
preferences, and national campaigns, such as
Choosing Wisely
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Comprehensive Quality Improvement:
Operational Performance Optimization
Value, Risk & Reward
V
Revenue – Revenue Integrity
Labor – Span of Control, HR
Supplies – Standardization & Utilization
Tech – EHR Optimization
Clinical – LOS, Utilization, Variability
Physicians - Enterprise & CARTS
Revenue – Patient Access, Denials
Labor - Process Innovation
Supplies – Purchased Services
Tech – EHR Implementation
Clinical – Value-Based Purchasing
(e.g., Readmissions)
Revenue – AR & Billing
Labor – Benchmarking
Supplies – GPOs & Pricing
Tech – HIS + Bolt-ons
Clinical – Effectiveness
Revenue – Call Center, Hospital
& Physician Integration
Labor – Shared Services
Supplies – Strategic
Relationships
Tech – Business Intelligence
Clinical – Integration/ Risk
Contracting/ Population Health,
Reinventing Care Delivery
Physicians – Network
Development
Scale - Merger/ Integration
Culture – Learning
Organization, Patient
Empowerment
Time, Complexity, & Difficulty
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Clinical Quality Improvement:
Three Core Metric Objectives
Functional
Status
Morbidity
Rate
Mortality
Rate
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Clinical Quality Improvement:
Impact Evaluation Metrics
Quality
Care gap closure
Peer review
Care pathway compliance
Satisfaction/Quality of Life
Patient satisfaction
Provider satisfaction
MD/staff retention rates
Efficiency/Risk
Acute Length of Stay by
DRG/CPT, etc.
Effective coding for
Population Health
Management
Process/Behavior Change
Health Risk Assessments
completed
ED wait times
Smoking Cessation
BMI Reduction
Outcomes/Health Status
Potentially preventable
admissions (PPAs)
Readmissions
Other potentially
preventable events
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Our Nation: Nutrition, Physical Activity, and Obesity
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Progress in Nutrition, Physical Activity, and Obesity
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Progress in Nutrition, Physical Activity, and Obesity
From 2008-2011, obesity among low-income preschoolers declined in 19 of 43 states and territories studied.
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Our Nation: Tobacco Use
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Tobacco Use
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Tobacco Use
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Collaborate
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Population Health – The First Line of Defense
The goal of population health management is to keep a patient population as healthy as possible,
minimizing the need for expensive interventions.
Accountable
Care
Coordinated
Care
Patient
Registries
Population
Health
PatientCentered
Medical Home
Care Teams
Disease
Management
 Proactive preventive and chronic care to all of a patients during and between encounters
 Manage high-risk patients to prevent them from becoming unhealthier and developing complications
 Use of evidence-based protocols to diagnose and treat in a consistent, cost-effective manner
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Population Health:
Transitioning to Value is a Huge Change
Current View
30 Patients per Day
14 have Chronic Conditions
Unknown Health Risks
Office Visits too short for coaching
Volume-Based/Episodic Care
New Population View
2500 Patient Population
900 have Chronic Conditions
1100-1250 have Moderate/High Health Risk
Care Teams leveraged by HIT
Value-Based/Continuous Care
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Population Health:
A Model
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Population Health
Dynamics:
Chronic
Disease
Payment
Rewards
Behavioral
Health
Health vs.
Care
Community
Health
Public
Safety
Public
Health
K-12
Education
Community
Investment
Ref.: Truman Medical Centers
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Population Health
Interactive Stakeholders:
Politicians
Health
Systems
Clinical
Providers
Pharma/
Medical
Devices/
Vendors
Payers
Patients/
Community
Patient/
Community
Advocates
Purchasers
Educational
Systems
Policy
Makers/
Advocates
Public
Health
Agencies
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Public Health and Healthcare
Opportunities to Work Together on Population Health
1
2
Linking the
Medical Home,
Public Health
Services and the
Hospitals
4
3
Quality
Improvement
5
Shared Health
Assessment and
Health
Improvement
Planning
Community
Engagement
6
Care Extension
and Case
Management
Source: Georgia Department of Public Health
Designing Billable
CommunityClinical
Interventions
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Doing Care Differently: Journey to a Healthier Kentucky
A Final Thought
Logic will get you from
A to B
Imagination will take you
everywhere
∞
- Albert Einstein
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Prepared by:
Phillip L. Polakoff, MD, M.Env.Sc., MPH
Senior Managing Director
Chief Medical Executive
Health Solutions
FTI Consulting
Phil.Polakoff@FTIConsulting.com
510-508-9216
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