Lessons from Healthcare Transformation August 5, 2014 The Six Campuses of NYP Weill Cornell Medical Center Payne Whitney Westchester Morgan Stanley Children’s Hospital The Allen Hospital Columbia University Medical Center Lower Manhattan Hospital 1 NYP Snapshot - 2013 Centers of Excellence CHILDREN’S CARDIAC DIGESTIVE NEUROSCIENCES ONCOLOGY TRANSPLANT *2011 Data 2 Affiliation with Two Premier Medical Schools 1771 – New York Hospital 1868 – Presbyterian Hospital 1898 – Cornell University Medical College (Now Weill Cornell) 1767 – Columbia University College of Physicians & Surgeons 1927 – Affiliation Agreement 1911 – Affiliation Agreement Both highly ranked by U.S. News 1998: NewYork-Presbyterian Hospital Over 1,600 residents 120 ACGME-accredited programs Single-site GME provider 3 NewYork-Presbyterian Healthcare System Facilities 30 Discharges 500,000+ Physicians 10,000 Care for NY Metro Area 21% of Discharges *Facilities include hospitals, nursing homes, & specialty institutions **NY Metro Area includes 5 boroughs of NY, Westchester, Rockland, Orange, Nassau; Fairfield and Litchfield, CT; Bergen and Hudson City, NJ 4 Common Problems: Higher Education & Healthcare Cost Declining government support Public perception / rankings Defining and measuring quality Regulation Business model disruption 5 College Tuition Has Outpaced Medical Inflation 6 And is Projected to Continue to Rise Significantly 7 Healthcare Spending Continues to Rise, and is Consuming More of the Economy 20% Actual Projected 19% 18% 17% 16% 15% 2006 2008 2010 2012 2014 2016 2018 2020 2022 Source: CMS (2012) 8 The US Healthcare System in Context 2012 Nominal GDP USA $15.7 Trillion CHINA $8.3 Trillion JAPAN $6.0 Trillion GERMANY $3.4 Trillion US Healthcare System $2.9 Trillion FRANCE $2.6 Trillion UK $2.4 Trillion BRAZIL $2.4 Trillion Source: CIA World Fact Book 2012 9 Common Problems: Higher Education & Healthcare Cost Declining government support Public perception / rankings Defining and measuring quality Regulation Business model disruption 10 Healthcare Spending Has a Large Opportunity Cost 11 Education & Healthcare Consumed Almost 2/3 of the 2014 NYS Budget Everything Else 11% Debt Service 7% School Aid & Special-Ed 28% Fringe Benefits 5% State Salaries 13% Higher Education (inc salaries) 12% Other Healthcare 6% Healthcare Medicaid 18% 12 Projected Financial Impact of Reform on NYP 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 $ ($50 M) ($100 M) ($150 M) Expanded Medicaid Coverage Value-Based Payments ($200 M) Fiscal Cliff (DCI cut) Readmissions ($250 M) 2% Reduction in Medicaid Reimbursement Rates Medicaid Elimination of Trend Factor Sequestration ($300 M) Employer Benefit Costs DSH Reductions Medicare Market Basket Adjustments ($350 M) ($400 M) 13 Common Problems: Higher Education & Healthcare Cost Declining government support Public perception / rankings Defining and measuring quality Regulation Business model disruption 14 Is a College Education Delivering Value? 15 High Prices, Poor Outcomes Source: OECD data 16 What Health Care Services Really Make a Difference? $750 Billion in Waste Prevention Failures Inflated Prices 7% 14% Excess Administrative Costs Fraud 10% 28% 25% 17% Inefficient Care Delivery Unnecessary Services Source: Institute of Medicine Report 2012 17 Healthcare Perception or Reality “Well Bob, It looks like a paper cut, but just to be sure let’s do lots of tests.” 18 Are We Spending Money on the Right Things? Source: Bipartisan Policy Center, “F” as in Fat: How Obesity Threatens America’s Future (TFAH/RWJF, Aug. 2013) Healthcare Costs Are Concentrated 23 Million Beneficiaries •Spending $1,130 each •Total Spending = 5% ($26 B) 16.1 Million Beneficiaries •Spending $6,150 each •Total Spending = 20% ($104 B) 7 Million Beneficiaries •Spending $55,000 each •Total Spending = 75% ($391 B) Common Problems: Higher Education & Healthcare Cost Declining government support Public perception / rankings Defining and measuring quality Regulation Business model disruption 21 Defining Quality 22 Proposed Quality Measures for Higher Education Student loan repayment and default rates Student progression and completion Institutional cost per degree Employment of graduates Student learning 23 Common Problems: Higher Education & Healthcare Cost Declining government support Public perception / rankings Defining and measuring quality Regulation Business model disruption 24 Regulatory Overhead Higher Education Healthcare Reporting: Clery Act, military & veteran complaints, etc Reporting: sentinel events, patient complaints Accreditation Accreditation (Joint Commission) Anti-trust Anti-trust Student disclosures Patient disclosures Internal audit & compliance Internal audit & compliance Higher Education Act (900 pages) Affordable Care Act (906 pages) 25 Unfunded Mandates in Healthcare EMTALA HIPAA Transition to ICD-10 coding MRSA testing for patients Quality & readmission penalties 26 Common Problems: Higher Education & Healthcare Cost Declining government support Public perception / rankings Defining and measuring quality Regulation Business model disruption 27 Disruption in Education 28 New Entrants in Healthcare Delivery 29 Consumer Expectations Changing Markets New Entrants in Healthcare 31 The Traditional Fee-For-Service Model is Changing Increasing Risk Fee-forService P4P / Penalties Bundled Payments ACOs/ Shared Savings Capitation Insurance Product 32 Population Health: Developing a Comprehensive Delivery System Specialists •Academic •Community PCPs Home Healthcare •Academic •Community Comprehensive Delivery System Post-Acute • Rehab • Long-term Care • SNF Hospitals Ambulatory Sites • Physician Offices • Diagnostics • Retail / Urgent Care Sites 33 The (R)evolution of Personalized Medicine Past Present Future Human Genome Project - first human genome sequenced in 2003 Targeted therapy around: • Breast, lung & colon cancer • BMT • Rare diseases • Warfarin “Inexpensive” sequencing means: • More discovery • Earlier diagnosis • More targeted therapy Genomes done infrequently $2.7 billion $2-4,000+ /test $15,000+ /genome $1,000 /genome U.S. Healthcare Delivery System Challenges Procedure-based reimbursement Fragmented care transitions Undifferentiated quality Immature information technology Demographics: aging population, chronic disease Innovation Cost shifting Lack of transparency 35 NYP Market Challenges Declining overall and commercial utilization Increasing pressure on payer mix and pricing Increasing level of hospital consolidation Consolidation and restructuring of the physician landscape, threatening existing informal referral relationships – Aggressive physician alignment by large healthcare systems in the NYC metropolitan area – Rapid growth of large suburban physician organizations 36 Change in Commercial Discharges from NYC 5-Borough & Westchester 25% 21% 20% 14% 15% 10% 5% 1% 0% -5% -1% -4% -1% -2% -3% -4% -6% -10% -8% -10%-9% -15% -15% -20% NYP North Shore/LIJ Continuum 2010 - 2011 (1 year period) NYU/Joint Diseases Montefiore Mount Sinai Total 5Boroughs & Weschester 2007 - 2011 (5 year period) Source: Truven 37 Demand Model: NYP’s Projected Discharges 140,000 130,538 130,000 120,000 122,483 117,853 110,000 99,499 100,000 113,471 115,411 95,774 97,411 2015 2019 90,000 80,000 70,000 2011 Loosely Managed Moderately Managed 8 Year Capital Plan Demand Model assumes that NYP will maintain constant share of the NY 5Borough and Westchester market 38 Projected Financial Impact of Reform on NYP 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 $ ($50 M) ($100 M) ($150 M) Expanded Medicaid Coverage Value-Based Payments ($200 M) Fiscal Cliff (DCI cut) Readmissions ($250 M) 2% Reduction in Medicaid Reimbursement Rates Medicaid Elimination of Trend Factor Sequestration ($300 M) Employer Benefit Costs DSH Reductions Medicare Market Basket Adjustments ($350 M) ($400 M) 39 NYC Key Competitors NYP Hackensack Montefiore Mount Sinai Health System NYU NSLIJ MSKCC Strategic Tension: Clinical Demand vs Business Profitability Clinical Program Analysis Strategic Business Analysis Epidemiology / Biostatistics Finance / Policy Modeling Modeling Evaluation Evaluation 41 42 Two Choices To Achieve Our Vision, NYP’s Business Model Is Built Around 6 Strategic Initiatives 44 Strengthening Health and Wellbeing at NYP Reaching multiple populations… Employees National Corporate International - National Regional Health Collaborative - International …of all health statuses… Healthy Acute Illness Chronic Illness …to deliver comprehensive care Primary prevention Acute episode Tertiary prevention HEALTH IT * 2017 represents when programs will be fully operational and mature Health and Wellbeing at NYP Primary Prevention – To protect individuals from developing disease Clinical Transformation: 360° Focus Health & Wellbeing Acute Care Tertiary Prevention – To manage complicated, longterm health problems and prevent disease progression Primary Prevention Tertiary Prevention Care Coordination Patient Engagement Program Evaluation & Outcomes Engage Staff & Patients Staff, Patient & Family Engagement Staff, Patient & Family Engagement Culture Patient Care Goal: To develop staff programs and practices that align with NYP’s values Goal: To enable patients to become more involved in their care by providing them with education and other necessary tools Environment of Care Goal: To improve quality of care and the patient experience by involving patients and families in policies, programs, and changes in care delivery Community Goal: To enhance population health by partnering with community based organizations Making Care Better A comprehensive, interdisciplinary redesign of clinical systems and processes to deliver greater value across the care continuum Key Concepts Promote integrated, team-based care Align people, process and technology Results Measurably improve quality Reduce waste, variation and duplication 48 MAKING CARE BETTER: Standardize and Coordinate Care & Practice within a Safe and Highly Reliable Culture Provide Highly Reliable Innovative Care Deliver & Demonstrate Value DOCUMENT PCP & referring MD (external) NYP Care team Admitting diagnosis Initial screening by care coordinator UTILIZE Daily interdisciplinary rounds Discharge bundle DETERMINE Availability & appropriateness of clinical pathway Eligibility for hospital ambulation Eligibility for palliative care EDUCATE NQF Teachback on patients for self-management skills Patients regarding portals (mynyp.org) COMMUNICATE Communication about errors Communication openness 49 ACO Governance NewYork-Presbyterian Hospital Weill Cornell Columbia Corporate Members NYP-CU-WCU Integrated Services, LLC ACO Board of Managers NYP Weill Cornell Participant Participant Columbia Participant Improve & Expand Access Network Development Manhattan 51 Large Scale Ambulatory Strategies are Needed to Address Geographic Coverage Needs Geographic area necessary to reach ~50,000 lives Source: Truven 52 Management Services The Future State is an Evolutionary/Hybrid Process Organizational construct to support an evolutionary model. Rapid change that doesn’t impact the quality/standards of NYPH. Functions may be at various stages of evolution, resulting in a hybrid model. Phase 1 - Build Growth/Accumulation (While maintaining certain brand/experience requirements) Phase 2 - Assimilation Integration/Standardization Phase 3 – Integrated Performance Unified Brand/ Consistent Delivery of Care/Economies of Scale 53 HERCULES HERCULES is a key hospital-wide initiative to cut costs & increase efficiencies while providing the highest-quality, most compassionate care & service to our patients Goal: Remove $150M of Cost in 3 Years Clinical Resource Optimization Making Care Better • Supply alternatives • Recycling opportunities • Reduce waste • LOS • Benchmarking Operational • Consolidation potential Excellence • Slowing growth rate • Ancillary utilization • Standardize Care Supply • Duplicative testing • Care Coordination Utilization • Practice variability 54 Information Technology and Innovation Information Technology Innovation Center 55 Deliver & Demonstrate Value Data Analytics Framework Governance • Stewardship • Data sharing Data Standardization Reporting & Monitoring • Retrospective & Real-time information • Data Dictionary • “Source of truth” • Process & outcome measures • Accountability • Privacy & Security • Population Management • Role-based dashboards Analytical Capability • Descriptive (what happened?) • Diagnostic (why did it happen?) • Predictive (what will happen?) • Prescriptive (what should happen?) IT Identify solutions to meet future unmet needs 56 Deliver & Demonstrate Value Data Analytics: Physician Reporting Department, Division, Physician CMO / Associate CMOs Division Chiefs Attendings Flow of Information and Accountability Department Chair Residents 57 Data Analytics: Nursing Unit Provide Highly Reliable Innovative Care Deliver & Demonstrate Value HERCULES Status as of July 22, 2014 Project Status (in milllions) $60.87 $58.70 $60.00 $5.94 $5.94 $45.00 $23.80 $23.66 Planned Underway $30.00 Done $21.63 $0.67 $6.63 $15.00 $16.20 $4.00 $11.55 $1.17 $1.52 $14.33 $11.49 $31.10 $29.10 $0.10 $4.55 $11.11 $8.83 $6.84 $1.10 $Operational Excellence Making Care Better/Patient Flow Supply Utilization Clinical Resource Optimization Grand Total Prior Month Total 59 60