Provider and Payer Partnerships to Improve Population Health

Transcription

1 Provider and Payer Partnerships to Improve Population Health Innovations in Care Delivery Conference March 23, 2016 Richard Martin, MD, FAAFP Director Continuum Care, Geisinger Health System Keith A. Boell, DO, FAAP, FHM Director of the Hospital Medicine Program, Geisinger Health System Agenda Context Marketplace structural change: Insurance and reimbursement Large employers and direct contracting Payers becoming providers and providers becoming payers Move to VBR forcing change in payer provider relationships Payer-Provider Partnerships Evidence-based strategies and experience from Geisinger Health Plan 2 Healthcare Market Transformation - Two Major Vectors of Change Insurance Coverage Transformation Care Delivery And Reimbursement Transformation Before and 2022 Regulatory Reform/Private Sector Restructuring Implementation and Adaptation Federal/state regulations New Normal Public exchanges open Interpretation and preparation Localized choice Private exchange adoption Private exchange Movement from B2B to B2C Level playing field & competition investments Benefit and network redesign Regulatory refinement Rationalizing DB health coverage/self vs fully insured Transparency Consumer activation and agitation Innovation, prototypes and New Normal proof of concept Volume to Value Broad range of collaborative Patient-centered medical Provider care models homes accountability/control (VBR) Provider-driven health Cost, quality and patient Bundled payment (warranty) management experience transparency Carve-in /re-aggregation of total Accountable care Competition based on cost and costs organizations quality Rapid adaptation/maturity of proven models of care delivery EHR, HIE and analytics Clinical data interoperability Emergence of new P4P, shared savings, shared enablers/intermediaries data, Radical improvement in quality risk 2016 Geisinger analytics, Health services, System & devices xg Health Solutions. and value 3 1

2 History of Payer-Provider Integration s Group/staff model HMOs (e.g., Kaiser, GHC, etc.) s IPA model HMOs (e.g., Hill Physicians s 1980s 1990s 1990s 1980s: Rural-based IDNs develop health plans (Geisinger, Carle, Scott & White, etc.) Insurers acquire primary care groups, investor-owned hospitals acquire insurers Insurers sell off primary care groups to PPMs Nonprofit hospitals get into insurer business in anticipation of capitated care partly stimulated by BBA 97 (Provider- Sponsored Organizations) Source: Lawton Robert Burns, Ph.D., MBA The James Joo-Jin Kim Professor Dept of Health Care Management The Wharton School 4 Significant Shift Toward Self-Funding Employers Bearing More Risk Direct Engagement with Providers Percentage of Self-Insured Employers Partially or Completely Self-Insured Employer Interest in Provider-Oriented Strategies 60% Adopt new accountable payment models 6% 20% 52% 55% 57% Contract directly with hospitals, physicians, ACOs 7% 13% 49% Offer incentives for care coordination 8% 21% Offer performancebased payments 12% % In Place in 2013 Planned for 2014 Source: Kaiser Family Foundation, 2012 Employer Health Benefits Survey, available at: Towers Watson, 18 th Annual Towers Watson Employer Survey on Purchasing Value in Health Care, 2013, available at: Health Care Advisory Board interviews and analysis and The Advisory Board 5 Large employers are increasingly partnering with hospital systems, primarily around bundled care for ortho/cardiac procedures for adults VMMC contract for cardiac and spine procedures with Walmart Black Hills Surgical Hospital agreement with South Dakota state employees for lowerback procedures Mayo Clinic agreement with Walmart for cardiac and spine procedures Northwestern Memorial Hospital agreement with GE for orthopedic procedures Not Exhaustive Cleveland Clinic agreement with Boeing, Walmart, and Lowe s for cardiac and orthopedic procedures UCSF contract for various procedures with CalPERS Geisinger agreement with Walmart for cardiac and spinal care Hoag contract for orthopedic procedures with Kroger employees Colorado Business Group on Health agreement with local employers for cardiac care Scott & White agreement with Walmart for cardiac and spine procedures Source: AonHewitt Johns Hopkins agreement with PepsiCo for cardiac and orthopedic procedures Carolinas HealthCare agreement with local employers for cardiac care Mercy Hospital agreement with Walmart for cardiac and spinal care Strong interest from employers in creating bundled payments around high volume procedures such as hips, knees and backs Source: FierceHealthcare; Advisory Board Company; L.A. Times; CalPERS; Journal of Healthcare Contracting; Modern Healthcare 6 2

3 Payers Becoming Providers Source: Revive Health Marketing 7 Providers Becoming Payers Provider/Payer Partnerships Defining the value of provider and payer relationships from the health plan perspective Defining the value of provider and payer relationships from the provider perspective Positioning your organization for healthcare reform by aligning goals and tactics 9 3

4 So. col lab o ra tion kəˌlabəˈrāsh(ə)n/ A recursive process where two or more organizations work together to realize shared goals part ner ship ˈpärtnərˌShip An arrangement where parties agree to cooperate to advance their mutual interests Trust: One party (trustor) is willing to rely on the actions of another party (trustee); the situation is directed to the future. The trustor (voluntarily or forcedly) abandons control over the actions performed by the trustee. As a consequence, the trustor is uncertain about the outcome of the other's actions; they can only develop and evaluate expectations. The uncertainty involves the risk of failure or harm to the trustor if the trustee will not behave as desired 10 Providers Trust Toward Payers Combined Trust Measures Reliability: organization makes every effort to honor its commitments Honesty: organization is accurate and honest in representing itself and its intentions Fairness: organization balances its interests with ours and doesn't routinely take advantage of us Combined Trust Index Score by Payor Source: ReviveHealth & Catalyst Healthcare Research Composite Trust Index Score values are calculated as an equally-weighted mean of all three individual Trust measures Survey of provider trust of payers Geisinger Health Plan Experience Evidence-Based Strategies in Payer Provider Partnerships Geisinger Health System & xg Health Solutions. 4

5 Provider/Payer Partnerships Trust Momentum Relationships Partnerships 13 Partnership of PCPs and GHP Provides 24/7, 360-Degree Patient Care and Navigation It Takes a Partnership: Each Party Doing What They Do Best Payer Population analysis Align reimbursement Finance care Engage member and employer Report population outcomes Take to market Provider Identify best practice Design systems of care Educate patient and family Deliver care Report patient outcomes Continually improve 15 5

6 Who? What Population? Segmented by: Group practice Employer group Coverage (line of business) Diagnosis (MS, diabetes) Region Town, community 16 Commercial TPA Client Risk Model High Risk 2% Membership 27% Total Cost Complex Case Management 186 Members Low Risk 75% Membership 38% Total Cost Moderate Risk 23% Membership 35% Total Cost One targeted chronic condition 1,665 members Health Management More than one targeted chronic condition 768 members Health Maintenance 7,657 members 17 Advanced Medical Home Primary Care Components Chronic, Serious Disease At-Risk Well Concentrated Care Embedded case manager Predictive analytics Transitions Care coordination Chronic Disease Care ID and stratify Self-manage Educate Close gaps in care Driving to goal Primary Care Practice redesign Automated prevention for all patients Health IT reinforces guidelines and best practices Patient education and activation Care team performance management process 18 6

7 Geisinger ProvenHealth Navigator Advanced Medical Home Model Health Affairs publication: April Population Management Care across the member s lifespan and healthcare needs - a redesign and building of a full continuum of population management Wellness Low risk Health promotion Health Management Moderate risk Disease or condition management Complex Case Management Highest risk Comorbid condition management 20 How? Getting Started Quality Pilots Example: ACE/ARB initiative, colorectal screens, high-cost imaging Pilot by program, geography, diagnosis Pay for Performance - P4P Shared savings models 21 7

8 Friedberg MN, et al. Ann Intern Med. 2009;151(7): Hong CS, et al. JAMA. 2010; 304(10): Value-Based Reimbursement Model Maintain Fee-For-Service PQS payments for quality Earn Results share incentive payment Opportunity based on efficiency Distributed based on quality 24 8

9 Physician Quality Summary (PQS) - Cervical CA - Mammography - Colorectal CA - Immunizations - ACE/ARB in Diabetes/HTN - Generic Dispensing - Adherence High-Risk Meds - Cholesterol - Diabetes - Strep Testing - Episode Profiler - ER Utilization 25 Proprietary Not for 25 reuse or distribution without permission. Scoring Methodology Acute Chronic Illness Preventive Health Medication Management Efficiency of Care Emergency Care Medication Adherence 5 acute / chronic care HEDIS measures 9 preventive health HEDIS measures m5 Medication HEDIS measures Comparison of cost calculations Emergency department utilization Adherence to medication to treat serious diseases 25% 25% 20% 10% 15% 5% 26 Performance Rating Good: The physician s score equaled the Health Plan s basic standards. Very Good: The physician s score was above the Health Plan s basic standards. Excellent: The physician s score exceeded the Health Plan s basic standards by a statistically significant amount. Updates of data occur in October Site scores are available to the public Individual provider scores only available to the provider 27 9

10 PQS Performance (Fall Cycle 2013) 28 Transforming Data into Information Information must be Timely Accurate Relevant Actionable Information is critical for use in longitudinal trending, benchmarking, and best practices. 29 Provider Quality Summary 30 10

11 Medication Adherence Profile 31 An Example: Kulpmont Clinic (Four Physicians; two FT, two PT and two PAs) Coronary Artery Disease (CAD) Patients, 562 Diabetes Patients PNU FLU A1C A1C <7 LDL LDL <100 KID TOB BP <130/80 Meet ALL Measures 14.5% Best Site 31% % Compliance 32 Variation Examples 33 11

12 Can We Change Behavior? 90% PCP Generic Dispensing Rate PCPs with more than 5200 scripts per year 88% 86% 84% 82% 80% 78% 34 Commercial 90% PCP Site Performance 30 Procedure Utilization 80% 20 70% Good 10 60% Good 50% HEDIS 2009 HEDIS 2010 HEDIS 2011 HEDIS HEDIS 2009 HEDIS 2010 HEDIS 2011 HEDIS 2012 A1c <8 LDL <100 BP <140/90 PCI Cardiac Cath CABG 35 Medicare PCP Site Performance Procedure Utilization 90% 30 80% 20 Good 70% 10 Good 60% HEDIS 2009 HEDIS 2010 HEDIS 2011 HEDIS 2012 A1c <8 LDL <100 BP <140/90 0 HEDIS 2009 HEDIS 2010 HEDIS 2011 HEDIS 2012 PCI Cardiac Cath CABG Carotid Endart 36 12

13 Attributes - Shared Savings Model Create incentive to reward practice transformation. Create targeted cost expectations based on historical experience. Protect against increases in underlying risk. Protect against catastrophic cases, which may have an overbearing impact on group results. Recognize Regression to Mean. 37 Shared Savings: General Methodology Creating a Target Two prior years PMPMs are trended forward and blended using book trends. Medicare vs. Commercial HMO vs. PPO Medical vs. Rx The use of multiple years prevents over-reliance on a single historical PMPM. Comparing Target to Actual Neutralize for changes in underlying risk. Any positive risk neutral delta between target and actual is considered savings generated by the program. Savings are split equally between GROUP and GHP, subject to attainment of quality goals. GHP funds care management infrastructure. 38 Example of Quality Metrics Quality Indicators Weight Bundles: maintain 3/5 bundles above the group standard, or improve 3/5 bundle %ile from previous year 30% PCP f/u: 75% or greater pt with f/u appointment within 7 days of d/c from Hosp or SNF and 25% or greater pts with f/u visit with provider within 3 days of hosp d/c for the following diagnoses: CHF exacerbation, copd exacerbation ( excluding planned readmissions) 10% SNF readmit rate: decrease readmit rate from previous year or maintain below the national standard 10% QI Project: addressing Ed utilization: develop a multidisciplinary care plan for pts with multiple Ed visits ( >3 in 6 mo) or Decrease number of low acuity Ed visits 10% Pharmacy: increase prescribing of ACE/ARB in appropriate diabetic population by 5% 10% Prevention: increase number of completed mammograms and FOBT testing 10% GHP Health managers: increase by 5%: referrals/ usage of the GHP health managers for appropriate diagnoses: DM, asthma, HTN, lipids, 10% Advanced illness: increase total number of days pts spend in hospice by implementing a process to increase: palliative care referrals, hospice referrals: with goal to improve End of life care, 10% Total 100% 39 13

14 PCHM - Specialty Integration Pilots Endocrinology Diabetes Nephrology Hypertension primary care trigger care pathway patient specialist medical home team primary care consult patient patient medical home team tests procedures mode of care specialist specialist patient specialist specialist patient Potential Areas of Care Improvement Rheumatology Thoracic Medicine Communication expectations tests tests procedures procedures communication communication 40 AIM FURTHER (Attribution, Integration, Measurement, Finances And Reporting of Therapies) Strategic approach biologics Which biologic? Too hot, not enough data Focus on efficacy Collect objective measures to assess if the drug is working If it s not working, stop using the drug! Focus on bookends What do we do BEFORE we start a biologic What do we do AFTER the patient has sustained disease control (de-escalation) 41 ProvenCare Modules Developed So Far Perinatal Care* CABG Bariatric Surgery COPD Total Hip Hip Arthroplasty Surgical Management of of Lung Cancer CHF Lumbar Spine Surgery Total Knee Arthroplasty Percutaneous Coronary Angioplasty Hip Fracture * has outpatient, as well as inpatient components 42 14

15 ProvenCare Chronic Disease Value-Driven Care Outcome Improvements Primary Care Diabetes Bundle Management: Three-Year Outcomes for Microvascular and Macrovascular Events (FBloom; TGraf; WStewart; GSteele, et. al. 2014;20(6); ) 43 The Functional Components of an Accountable Care Organization (ACO) Cultural Transformation Value-Driven Acute Care: Proven Care Acute Value-Driven Population Care Advanced Medical Home Clinical Redesign Value Driven Post-Acute Care: TOC, SNFist Value-Driven Specialty Care: AMH Integration Data-Driven Care and Leadership Evolutions Value-Driven Actuarial and Operational Informatics 44 Questions? 15