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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. What we’re facing…. Constraining the growth of healthcare costs is a national priority

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Partners Approach to Meeting the Healthcare Cost ChallengeTimothy Ferris, MD, MPHSVP, Population Health Management, MGH, MGPO and Partners HealthCareNuffield Trust Health Policy Summit 2014March 6, 2014

what we re facing
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

2

implications for providers
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
    • We need tactics that will be successful under any new payment model
    • How to make external incentives meaningful to our physicians
    • 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

3

what is an aco
What is an ACO?

Total Accountable Care Organizations by Sponsoring Entity

  • 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
  • Defined population = every primary care patient whose insurer has signed a risk contract with that provider, regardless of where they receive care

Total = 606

An organization that agrees to share the financial risk for the care of a defined population

Source: Leavitt Partners Center for Accountable Care Intelligence at http://healthaffairs.org/blog/2014/01/29/accountable-care-growth-in-2014-a-look-ahead/

4

evolution of acos
Evolution of ACOs

Estimated Accountable Care Lives in Public and Private ACOs*

  • 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.***
  • 18.2m covered lives compared to 13.6m at end of 2012

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

5

background on partners healthcare
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

6

the path we re traveling at partners
The path we’re traveling at Partners

Pressure to reduce

cost trend

New contracts with

risk for trend

Changes to Partners

org structure

Investment in Population

Management Infrastructure

Internal Performance

Framework

Network Affiliations

1

3

4

Partners in Care (PCMH & care

coordination for high risk patients)

Implement new local

incentives/compensation

New relationships with community hospitals and doctors

2

Enhanced access to specialty services

Sustained cost trends near GDP

7

our new contracts almost 2 years in lives under the accountable care model
Our new contracts…almost 2 years inLives under the Accountable Care Model

1

2

3

4

Medicare

Commercial

Medicaid

Self Insured

Alternative Quality Contract (AQC)

Younger population, specialists critical to management

NHP

Population with significant disability, mental health, and substance abuse challenges

Partners Plus

Commercial population, but savings accrue directly to Partners, and improves our own lives

  • Pioneer Accountable Care Organization
  • Elderly population, care management central to trend management

Covered lives: ~75k

Covered lives: ~350K

Covered lives: ~25K

Covered lives: ~80k

Partners currently manages roughly 500,000 lives in various accountable care relationships

8

virtual visits and technology tools
Virtual visits and technology tools

Technology

  • Pediatric Virtual Video Pilots
  • Follow up visits in the home for children and adolescents with Autism, ADHD, Substance Abuse, etc,
  • Post-acute burn consults for patients at Boston-Spaulding Rehabilitation Hospital
  • Parents of patients in the PICU virtually attend rounds with care team and their child

Email

Video Conferencing

Telephone

Cardiology Curbside Consults*

  • 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

Text

Messaging

Electronic Curbside

*Start of pilot Jan 2014

10

approaches for managing referrals
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.

  • 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

11

idealized patient journey through an episode of care that includes a procedure
Idealized patient journey through an episode of care that includes a procedure

Assess Appropriateness Criteria

Shared Decision Making

Personalized Consent Form

Tier 1, 2 Outcome Measures

Tier 3Outcome Measures

Assess Risk

Patient Problem

Physician encounter

Schedule OR

Pre-ProcedureTesting

Procedure

Recovery

Informed Consent

Possible Need for Procedure

Outcome measures hierarchy:

12

proe inputs and outputs
PrOE: Inputs and outputs

INPUTS

OUTPUTS

PrOE Appropriateness tool

Procedure Scheduling

Appropriateness Indications & Decision support

Pre-populated data fields (NLP search)

Internal Performance Dashboards

LMR, OnCall

EMR

Public Reporting

Appropriateness Data Repository

EHR note created

Data storage

RPM, RPDR, CDR, EMPI

Billing and Prior Authorization

Copy of appropriateness results placed in LMR and CDR

Measurement & analysis of appropriateness and outcomes inform guidelines and indications in real-time

Personalized consent form

Existing registries

PCI, CABG, Vascular, Harris Joint

Data passback to registries (Web service)

results to date
Results to date

Percent of Procedures with a PrOE Assessment

  • 2014 Procedures
  • Incisional Hernia
  • Prostate Biopsy
  • Gastric Bypass
  • Valve Repair
  • Lumbar Fusion
    • Peripheral Vascular Disease Therapies

Appropriateness Scores for Diagnostic Catheterization by Month

Appropriateness Scores for Diagnostic Catheterization at MGH vs. NY Cardiac Database **

Median hospital-level inappropriateness rate is 28.5%**

**Hannan, EL, et al. Appropriateness of Diagnostic Catheterization for Suspected Coronary Artery Disease in New York State. CIRC INTERVENTIONS. January 28, 2014. 113.000741

n=745

n=8986

patient reported outcome measures proms
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?
    • 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
  • 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:
    • Coronary Artery Disease: CABG, Cardiac Catheterization
    • Osteoarthritis
    • Valvular Disease
    • Diabetes
    • Depression
    • Additional conditions planned for 2014
what does phm cost
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 CostPHM Programs (Annual Operating & 1x expense)

what is the roi
What is the ROI?

PHM Program Savings Relative to Total Operating Program Costs (Assumes Steady State in 2017)

  • 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

Total PHM Acceleration Cost

Savings from External Risk

Savings from full IPF

Savings from full panel (Loyalty Cohort)

key challenges
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

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

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