Population Health Management Defined
April 12, 2015
TIM MIKSCH, SECTION HEAD, APPLIED CLINICAL INFORMATICS
The Mayo Clinic
CLAUDIA BLACKBURN, SENIOR MANAGER
Aspen Advisors, Part of The Chartis Group
DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.
Conflict of Interest Disclosure
Tim Miksch, MBA
Has no real or apparent conflicts of interest to report.
Claudia Blackburn, MBA
Is employed by Aspen Advisors, Part of The Chartis Group, which
provides services that are discussed as a part of this presentation.
© 2014 HIMSS
Learning Objectives
• Identify how to align an organizational healthcare model with a valuebased reimbursement model to support the allocation of resources for high
risk patients
• Explain definitions and concepts associated with Population Health and
Population Health Management
• Summarize the role of analytics in developing and evaluating programs
and processes
• Identify where your organization is on a Population Health Management
(PHM) maturity roadmap
PHM
Core
Competencies
Case Study
Challenges
and Next
Steps
An Introduction to the Benefits Realized
for the Value of Health PHM IT
http://www.himss.org/ValueSuite
Population Health Management (PHM)
The Future of Healthcare Paradigm Shift
Today:
Reactive and
Volume-based
The Future:
Proactive and
Value-based
Drivers
Encourage
me!
Educate
me!
Health Reform
Population health management
provides comprehensive
Affordability Gap
authoritative strategies for
Triple Aim
improving the systems and
Weight of the Nation
policies that affect
health care quality, access,
Reimbursement
and outcomes, ultimately
improving the health
of an entire population
Treat
me
holistically!!
I will pay
you!
Individuals are accountable for their health
with the health system as their health
advocate.
Achieving Success
Making the “Triple Aim” Possible
Engaged Communities
Engaged Patients
•
•
•
•
• Identified and incorporated
Proactive care processes
Identified patients
Focused on wellness
Community resource navigator
•
Better
Health
for the
Population
•
•
patient goals
Focused on continuity and
coordination
Facilitated communication
channels
Improved access to care
Identified Opportunities to Reduce Waste
•
•
•
•
•
•
4 Rights
Duplication avoided
Improved coordination/transitions
Used automation to reduce resource needs
Improved screening and prevention
Aligned incentives to drive value
7
Population Health Management
Core Competencies and Key Pillars
Population Health Management (PHM)
Core Competencies
The goal of population health is to transform care delivery practices and
administrative support to deliver improved outcomes and lower costs across the
continuum of care for a specified population. Success will depend on changes in care
practices, business processes and cross-organizational communications, all
supported by information technology.
Member Engagement
Operational Performance
Management and BI
Cross-Continuum Care
Delivery and Medical /
Care Management
Accounting
Quality Outcomes
Management / Reporting
Integration and Infrastructure
Key Pillars of
Population Health Management
Business vision,
population definition,
policies, modeling,
financials, contracts,
procedures, market
analysis, and value
proposition
Risk, incentives,
payment management,
shared savings
Workflows, role changes,
people, care coaches,
wellness program
development, heath risk
assessment process,
population engagement
Integration and
interoperability
including HIE, patient
portal, analytics,
coaching tools and
health risk assessment
Mayo Community Practices
MAYO CLINIC in the MIDWEST
Academic Medical Center
Rochester, MN
Community and Regional Health System
75 communities in MN, IA and WI
•
•
•
•
•
•
•
500,000 patients/year
2,000 physicians
125 primary care providers
Primary care
At full risk for PC
4 regions
18 hospitals
525,000 patients/year
1,000+ physicians
Primary care
At risk for PC
MAYO CLINIC in the SOUTHWEST
MAYO CLINIC in the SOUTHEAST
Arizona
Florida
•
•
•
•
90,000 patients/year
Approx. 400 physicians
90,000 patients/year
Approx. 400 physicians
Primary care
Primary care
At full risk for PC
At full risk for PC
Office of Population Health Management
• Formed in 2012
• Developed a Mayo framework for PHM
– Strategy
– Phasing
– Oversight
– Coordination
– Standardization
• Focused on the community practices
• Initially focused on primary care
• Value-based care
– Patient-Centered Medical Home
– Risk based reimbursement
The Changing Market
100%
Full population care
80%
Partial population care
60%
40%
Condition-based care
Episode care
20%
Fee-for-service
0%
2010
2015
2020
Source: “The View from Healthcare’s Front Lines: An Oliver Wyman CEO Survey”
WHY?
Our survival Small changes
is at risk
are not
enough
Costs are rising
Reimbursement
is decreasing
WHO?
Office of Population A new way
OPHM defines
Health Management of practicing strategy for the
is needed
(OPHM)
new model
The measure of
PRODUCTIVITY is
no longer VOLUME
Outcomes + Service
It is VALUE =
Cost
OPHM establishes the
STANDARDIZED ELEMENTS
for clinics to implement with
APPROPRIATE LOCALIZATION
Created by MCCPC to
TRANSFORM Community Care
WHAT?
The Mayo Model of
Community Care
(MMoCC)
Implemented in
strategic phases
Changing
isn’t just for
survival
The new model
allows us to
thrive
MMoCC is an enterprise-wide,
multi-year roll-out to achieve the
TRIPLE AIM:
• Improve Population Health
• Improve Individual Experiences
• Lower Costs
While aligning with financial models
Vision
Patient centered, integrated care delivery model
based on:
• Aligned incentives
• Coordinated, collaborative processes
• Evidence-based prevention and disease
management protocols
• Seamless sharing of information
Supported by wellness and continuity care
programs that focus on:
• Patient engagement
• Community integration
• Prevention and health promotion
Driven by analytics to support quality outcomes and
value-based accountable reimbursement
Mayo Clinic Clinical Practice Committee
Office of Population Health
Management
OPHM
Advisory Group
Executive Team
Programs
Functional
Subgroups
Geographic
Operations
Health & Wellness
Continuity Care
Prevention
Care
Coordination
Change Mgmt./
Communications
Arizona Office
Chronic Condition
Management
Data Analytics
Florida Office
IT Tools and
Application
Midwest Office
Community
Engagement
Palliative Care
Care
Transitions
Wellness
Team-based Care
Patient Engagement
Access
MMoCC Focus Areas
COST
PHM FOCUS
50%
• Care Coordination
• Care Transitions
• Palliative Care
35%
15%
35%
• Disease
Management
Care teams
Patient
engagement
Community
engagement
15%
50%
• Wellness
• Prevention
Access
P O P U L AT I O N
% of community
2010 data from Mayo Clinic Health Sciences Research
MMoCC Impact
Identify opportunities
Act on opportunities
Ability to impact
80% of costs
Situational
risk
Early risk
High risk
Symptomatic
illness
• Family Hx
• Environment
• Diet
• Exercise
• Cholesterol
• BP
• Blood sugar
• Active Dz
• Diabetes
Lifetime
Complex
active
illness
MMoCC Process
1
2
3
DEFINE
ASSESS
STRATIFY
Population Identification
Health Assessment
Risk Stratification
4
5
ENGAGE
MANAGE
Enrollment / Engagement Strategies Management / Interventions
Tailored Interventions
—
Care Coordination
—
Disease / Case Management
—
Health Risk Management
—
Health Promotion / Wellness
Meeting patients where they are
…physically
home | school | work | shopping | in the clinic
…in the way that works best for them
email | text | internet | phone | video | face-to-face
Phased Implementation
MMoCC 4
MMoCC 3
More site resource
investment – mixed
volume/value
MMoCC 2
Laying the foundation while
living in FFS
• Shifts from individual
• Introduces value-based (TCOC)
•
•
•
concepts and model (change
management)
Emphasis on team-based care
foundation and care coordination
introduction
Standardized disease management
and prevention recommendations
Focus on decreasing high utilization
where it makes sense (30 d
readmits…)
•
•
•
practice to team-based
panels
Continues focus on high
utilization and expanded
analytics and care
management
Increases focus on patient
important outcomes
Strong shift to total cost of
care drivers
Requires value-based
contracts to succeed
• Adds specialty
integration to care team
concept
• Community
engagement
• Full alignment of
incentives
Diffusion Timeline
MMoCC Limited
Implementation
2013
2014
2015
2016
PILOT 4-6 Sites
MMoCC Previous
MMoCC 2
Foundation
MMoCC 3 Mixed
MMoCC 4 TCOC
2015 Status
• All sites are actively engaged
• Standardizing across sites and regions is a challenge
• For many, fee-for-service remains a driver
• Data management processes are maturing
• Keys to our success:
– Engaged leadership at local levels
– Institutional support
– Strong physician leaders in each program
– Excellent business analysis, project management and
informatics support in place
Structure
Demand for healthcare
Supply of resources to meet demand
Our pay will be based on VALUE = Outcomes + Service
Cost
We need to utilize our staff wisely through
TEAM-BASED CARE
Identify opportunities to impact health earlier and act on those opportunities
ANALYTICS
PREVENTION
DISEASE MGMT
CARE MGMT SYSTEM
We need to think differently about how to activate our patients and communities
PATIENT ENGAGEMENT
COMMUNITY ENGAGEMENT
WELLNESS
And how we interact with them
ACCESS
CARE COORDINATION
PALLIATIVE CARE
CARE TRANSITIONS
Analytics and Reports Examples
Report Description
Registration
• Unassigned and wrongly assigned patients
• Unassigned Emergency Department high utilizers
Care Coordination
• Diabetic Mellitus (DM) patients who are most likely to be readmitted
• Congestive Heart Failure (CHF) patients who are most likely to be readmitted
• 30 day readmission reports are located within the Care Coordination dashboard
with DM and CHF 20%. Follow instructions from section 2.1 and 2.2
Patients by Disease Evidence Type
• Patients with no Diabetes diagnosis but have other evidence of Diabetes
• Patients with no CHF diagnosis but have other evidence of CHF
Example Use from Care Coordinators
• Care Coordinator identified a patient based on ER visits and
reached out to her. She was very interested in COMPASS and did
the PHQ9, and it was 17.
“She was very interested in changing her life so that she could be
around for her granddaughter. I have sent her a letter and will keep
her on my watch. It was a good connection to at least let her be
aware that services are available if and when she is ready.”
• “I have a patient who, because of care coordination, has improved
her health to move from the PHM tool CHF “most” to the “more” list.
The PHM tool still identifies her as higher risk, but she has done
well with care coordination.”
• “It mostly has been helpful to me to identify patient populations that
might be eligible for care coordination to reach out to the providers
to get them on board with care coordination, pointing out that the
PHM tool has already identified them as being higher risk.”
Challenges and Next Steps
CHALLENGES
• Practice standardization
• Resources
–
Can’t stop processes and can’t add
resources to change
–
Needed to understand practice variation
and standardize
–
Informatics knowledgeable in in EMR
support teams
• Challenge to implement tools to free
up resources when processes and
data aren’t standardized
(IT, informatics)
• Rapid cycle iteration is challenging
for practice tools without significant
resource involvement
• Decision rights – “who says this is
the new process….”
2015 NEXT STEPS
• Enterprise metrics
• Point-of-care registry and care
management
• Patient consumer engagement
utilizing EMR patient portal
An Introduction to the Benefits Realized
for the Value of Health IT
http://www.himss.org/ValueSuite
Questions?
Thank You!
Tim Miksch
The Mayo Clinic
tmiksch@mayo.edu
@tmiksch
Claudia Blackburn
Aspen Advisors, Part of the
Chartis Group
cblackburn@aspenadvisors.net
@cblack67