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Session #21 Key Principles and Approaches to PHM

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1 Session #21 Key Principles and Approaches to PHM
Greg Spencer, MD Chief Medical & Chief Medical Information Officer, Crystal Run Healthcare Dr. Greg Spencer is the Chief Medical Officer and Chief Clinical Information Officer at Crystal Run Healthcare. He graduated from the Medical College of Wisconsin and completed residency training in Internal Medicine at Wilford Hall US Air Force Medical Center in San Antonio, TX, where he was chief resident and assistant director of the Internal Medicine Residency program and attained the rank of major. He is board certified in Internal Medicine and a Fellow of the American College of Physicians. Sreekanth Chaguturu, MD Vice President for Population Health Management, Partners HealthCare David A. Burton, MD Former Chairman and CEO, Health Catalyst, Former Senior Executive, Intermountain Healthcare Dr. Sreekanth Chaguturu is Vice President for Population Health Management at Partners HealthCare. He provides clinical oversight to population health management clinical programs, assists in management of clinical relationships for risk contracts with commercial and government payers, as well as oversight for Partners’ self-insured health plan. In these roles, he leads the assessment and development of information technology and analytic solutions to support population health programs. Dr. Chaguturu is also an Instructor in Internal Medicine at the Harvard Medical School and an attending physician at Massachusetts General Hospital. Dr. David A. Burton is the former Executive Chairman and CEO of Health Catalyst, and currently serves as a Senior Vice President, future product strategy. Before his first retirement, Dr. Burton served in a variety of executive positions in his 23-year career at Intermountain Healthcare, including founding Intermountain’s managed care plans and serving as a Senior Vice President and member of the Executive Committee. He holds an MD from Columbia University, did residency training in internal medicine at Massachusetts General Hospital and was board certified in Emergency Medicine.

2 Poll Questions (1-3) Does your organization sponsor or participate in a population health management/shared accountability initiative (e.g., ACO or commercial) Yes No Not sure Not applicable What percent of your patients are covered by your organization’s population health/shared accountability initiative? Less than 5% 5-10% More than 10% No idea In your opinion, how successful has your organization’s population health/shared accountability initiative been to date? Not at all successful Slightly successful Somewhat successful Successful Very successful Unsure or not applicable

3 Gregory Spencer MD FACP
Chief Medical Officer Crystal Run Healthcare

4 Our Approach Triple Aim as an organizational outline
Better care, better health, lower cost Analytics: multisource, scalable platform Provider involvement Care managers, CARETEAM, Telehealth Monitor the data

5

6 NY Healthcare Environment
Massive consolidation and mergers Bankruptcies Larger systems and groups Optum Venture capital Mostly unmanaged Urgent care centers and retail medicine

7 Crystal Run Healthcare
Physician owned MSG in NY State, founded 1996 300+ providers, 20 locations Joint Venture ASC, Urgent Care, Diagnostic Imaging, Sleep Center, High Complexity Lab, Pathology Early adopter EHR (NextGen®) 1999 Accredited by Joint Commission 2006 Level 3 NCQA PCMH Recognition , 2012

8 Crystal Run Healthcare ACO
Single entity ACO April 2012: MSSP participant December 2012: NCQA ACO Accreditation 35,000 commercial lives at risk MSSP 11,000 attributed beneficiaries 82% primary care services within ACO

9 Business Intelligence Past
Initially BI = business only, reports Quality, safety measures and clinical performance later Basic tools: SQL, SSRS, Excel Manual and time consuming Report generation > analysis Lack of scalability and extensibility Mostly tabular / numeric

10 Dashboards

11 Business Intelligence Now
Central EDW- many sources, fewer joins Scalable More analysis, less reporting Self-service and drill down Consume and deliver information Visual

12

13 Basic System Needs Common integrative platform
Pull together disparate data Cost: claims where available, internal costs A way to implement change “Leakage” and network Where are patients going, are needs being met? Lean Waste reduction, everywhere

14 How we chose our EDW Our bias: controlled by us Avoiding “black boxes”
Prior healthcare experience Modern technology Established track record Teach us how to fish

15 Crystal Run EDW Roadmap
Ambulatory discovery apps Cohort Builder Key Process Analysis Regulatory Explorer Risk Stratification and Predictive Analytics Ambulatory foundation apps 8 registries Ambulatory Population Explorer Practice Management Explorer Ambulatory advanced apps Population modules Population Health Dashboard Others IDEA data entry

16 Improving the patient experience
Web Portal Care Managers Shadow Coaching Choosing Wisely Practicing Excellence

17 Variation Reduction Specialty and division sponsored
Best practice review Buy-in at the physician level Provider projects Innovation contest National: Choosing Wisely Improved access - backfill and market share

18 Variation Reduction This table shows the reduction in visits per patient for the initial 15 diagnoses evaluated. Through adherence to best practice guidelines, approximately 13,000 visits were eliminated, creating capacity to care for additional patients.

19 Variation Reduction Improves Access
Creating a culture of efficiency has improved access in our organization. Assuming that the average physician sees 3,612 visits/year (MGMA), we have “created” 12 “new” physicians. Widespread adoption will mitigate the projected physician shortage. 41,823 fewer visits 30,206 more patients “Created” 12 physicians

20 Reducing Pharmaceutical Costs
PEG Filgrastrim cost per patient before and after breast cancer pathway Variation between physicians has to do with patient populations and stage of disease treated and percentages of patients on pathway and off pathway

21 Total cost difference (equalized as cost per patient treated)
PEG-filgrastim use in Breast cancer patients 2012 pre-pathway 791 patients $595,920 2013 post-pathway 817 patients $368,160 TOTAL COST SAVINGS $227, 760

22 Summary Triple Aim, core values as a guide
Unified analytics platform that integrates disparate systems is required Quality, safety and performance programs that are tracked Physician involvement, variation reduction Patient experience Leakage, where and why Systematically find and reduce waste

23 Sreekanth Chagaturu, MD
Medical Director for Population Health Management Partners HealthCare

24 Chapter 2: Innovations in Population Health Management Sree Chaguturu, MD Vice President, Population Health Management, Partners Health Care

25 My goals for today Describe Massachusetts health reform efforts
Provide overview of Partners Healthcare Review select programs

26 Patient Protection and Affordable Care Act
THREE POLICIES MAKE THIS EASIER -- Payment reform that rewards better outcomes and forces differentiation -- HITECH ACT to get computers in the office so we have capability -- HDI to liberate data to fuel innovative products Patient Protection and Affordable Care Act

27 My fair city…

28 Chapter 58 of the Acts of 2006: An Act Providing Access to Affordable, Quality, Accountable Health Care

29 Increasing health care spend in Mass crowded out all other areas

30 Health care reform part two

31 Who We Are: Partners HealthCare
Teaching Hospitals Massachusetts General Hospital Brigham and Women’s Hospital Community Hospitals Newton Wellesley Hospital North Shore Medical Center Martha’s Vineyard and Nantucket Hospitals Non Acute Care Spaulding Rehabilitation Network Mental Health Care McLean Hospital Community Provider Network Partners Community Health Care Community Health Centers

32 Partners HealthCare across eastern Massachusetts
Salem & Shaughnessy Partners Acute Hospitals Kaplan Union McLean Partners Specialty Hospitals Spaulding Towns With PCHI Primary Care Newton - MGH BWH Care Physician Practices Wellesley Faulkner Partners Home Care Branches RHCI

33 What we do Our Employees Our Patients Teaching Clinical Research
~60K employees – the largest non-government employer in the state ~13K are MDs, RNs and direct care givers ~5K are primarily involved in research Our Patients ~1.6M ambulatory visits ~168K discharges ~4K licensed beds ~$205M investment in community benefits Teaching 28 residency programs provide training to ~1,400 residents ~$ 167M investment in teaching Clinical Research ~$1.6B in academic/research revenue ~2,800 paid researchers (MDs & PhDs)

34 Partners currently covers over 500,000 lives in an accountable care contract
1 2 3 4 Medicare Commercial Medicaid Self Insured Example: Pioneer ACO Covered lives: ~74k Example: Alternative Quality Contract Covered lives: ~350K Example: NHP Covered lives: ~30k Example: Partners Plus Covered lives: ~100k

35 Partners is implementing over a dozen PHM Programs
Primary Care Patient Centered Medical Home (PCMH) High risk care management (palliative care) Mental health integration Virtual visits Specialty Care Active referral management (eConsults/curbsides) Procedural decision support (appropriateness) Patient reported outcomes Episodes of care (bundles) Care Continuum SNF care improvement (network/waiver/SNFist) Home care innovation (mobile observation/telemonitoring) Urgent care Patient Engagement Shared decision making Customized decision aids and educational materials Infrastructure Single EHR platform with advanced decision support Data warehouse, analytics, performance metrics

36 And why these programs? Develop team based care
Primary Care Patient Centered Medical Home (PCMH) High risk care management (palliative care) Mental health integration Virtual visits Specialty Care Active referral management (eConsults/curbsides) Procedural decision support (appropriateness) Patient reported outcomes Episodes of care (bundles) Care Continuum SNF care improvement (network/waiver/SNFist) Home care innovation (mobile observation/telemonitoring) Urgent care Patient Engagement Shared decision making Customized decision aids and educational materials Infrastructure Single EHR platform with advanced decision support Data warehouse, analytics, performance metrics Develop team based care Promote Medical Neighborhood Demonstrate value in procedures Reduce post acute variation Empower patients in their care Information -> Insight -> Action

37 High risk patients - those at risk of being high cost
Successful ACOs will use predictive analytics to launch a high risk care management program High risk patients - those at risk of being high cost Medically Complex Not Chronically Ill, Medically Complex Primary Care

38 Significant opportunity in integrating mental health services into primary care
Mental Health Disorder Chronic Condition Key Elements Examples [Current and Future] Better identify patients Increased screening Better triage of patients Phone access line with referral support Patients with a mental health disorder have 40% higher chronic condition costs Better use of protocols IMPACT for depression, SBIRT for substance abuse Better self-management Online patient-directed therapy (iCBT) Better access to services Embedded mental health resources, consulting psychiatrist Better tracking outcomes IT tools tracking longtitudinal progress, Patient reported outcomes measurement Primary Care 38

39 Virtual visits allow us to connect to patients in more convenient ways (and avoids unnecessary office visits) Synchronous Models that allow people and providers to connect in real time Asynchronous Models that deliver care to people without requiring real-time interaction Specialty Care

40 Patient Reported Outcome Measures are outcomes that matter (and demonstrates value to market)
Direct collection of information from patients regarding symptoms, functional status, and mental health. Surgery Tier 3: Sustainability of Recovery Functional Status time Tier 1: Health status achieved Tier 2: Process of Recovery Specialty Care

41 We can improve a patient’s surgical journey (and avoid unnecessary or unwanted surgeries)
PROMs PrOE (Procedure Decision Support) PROMs Assess Appropriateness Criteria Shared Decision Making Short-term Outcome Measures Long-term Outcome Measures Personalized Risk (Consent Form) PROs Survey(s) Patient with a Surgical Problem Physician Encounter Possible Need for Procedure Informed Consent Schedule OR Pre-Procedure Testing Procedure Recovery Milford CE, Hutter MM, Lillemoe KD, Ferris TG. (2014). Optimizing appropriate use of procedures in an era of payment reform. Annals of Surgery 206(2): Specialty Care 41

42 We target the most costly procedures
Nationally, these 7 procedures account for $56.6 billion, or 55% of the total costs of the 20 most costly procedures in the US: Spine fusion Spine laminectomy Knee arthroplasty Hip replacement PCI CABG Heart valve repair Specialty Care

43 Ultimately, we have created a more efficient prior authorization
Clinical Office Patient visits surgeon and lumbar laminectomy is indicated Admin faxes form to admitting Yes Patient undergoes procedure Admin knows procedure requires PA? Admitting calls clinic to work through PA form PrOE completed Surgeon schedules procedure Potential savings: Current process: 4-5% denial rate, <1% ultimately denied PrOE process: Produces same result (<1% denial rate) Reduces administrative burden MGH Admit-ting Admitting enters auth # in PATCOM No PrOE PA form sent to Admitting Admitting checks for form Admitting checks for form Decision submitted to Admitting Denied Authorization submitted to Admitting Manually appeal claim Payer Admitting submits PA PA is granted without third party review PA reviewed by third party Specialty Care

44 Redundant, inconsistent, and perishable educational
We can do a better job in helping our patients understand their healthcare encounters…. Problem Outcome Redundant, inconsistent, and perishable educational encounters in healthcare Reduced provider productivity and patient satisfaction Patient Eng.

45 Improved provider productivity and patient satisfaction
… by providing a non-perishable, personalized solution to patient education Outcome Solution Problem Improved provider productivity and patient satisfaction Provider-generated, video-based education prescribed to patients before, during, and after clinical encounters. Redundant, inconsistent, and perishable educational encounters in healthcare Patient Eng.

46 We believe personalized non-perishable education will improve outcomes and satisfaction
Series of short, single-topic videos featuring a patient's own healthcare provider. Improve provider efficiency, increase patient engagement, and improve clinical outcomes Patient Eng.

47 Thank you! Thoughts or questions?

48 Appropriateness Results: Diagnostic Cath
Appropriateness Scores for Diagnostic Catheterization by Month (all AUC Indications) Appropriateness Scores for Diagnostic Catheterization for Suspected CAD at MGH vs. NY Cardiac Database* Median hospital-level inappropriateness rate is 28.5%* n=156 n=8986 *Hannan, EL, et al. Appropriateness of Diagnostic Catheterization for Suspected Coronary Artery Disease in New York State. CIRC INTERVENTIONS. January 28,

49 PrOE: Inputs and 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)

50 Analytic Insights Questions & Answers A

51 Session Feedback Survey
On a scale of 1-5, how satisfied were you overall with this session? Not at all satisfied Somewhat satisfied Moderately satisfied Very satisfied Extremely satisfied What feedback or suggestions do you have? On a scale of 1-5, what level of interest would you have for additional, continued learning on this topic (articles, webinars, collaboration, training)? No interest Some interest Moderate interest Very interested Extremely interested Follow up group participation 1Would you like to participate in a follow up group on this topic that would meet 2-3 times next year to share progress, challenges and best practices? (Yes, No)

52 Upcoming Keynote Sessions
Location Main Ballroom 2:20 PM – 3:10 PM Predictive and Suggestive Analytics Dale Sanders Senior Vice President, Health Catalyst 3:25 PM – 4:25 PM From The Heart: Healthcare Transformation From India To The Cayman Islands Chandy Abraham, MD Chief Executive Officer, Director of Medical Services Health City, Cayman Islands Gene Thompson, Health City Director, Director of Thompson Development, Ltd. 4:15 PM – 4:45 PM Closing Keynote Dan Burton, Chief Executive Officer, Health Catalyst Follow up group participation 1Would you like to participate in a follow up group on this topic that would meet 2-3 times next year to share progress, challenges and best practices? (Yes, No)


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