1. 1 POPULATION HEALTH a health plan medical director perspective Healthcare Financial Management Association November 3, 2015 Marvin J. Gordon, M.D., FACG Regional Medical Director Health Net of California

2. Willie Sutton 2

3. % population - % cost 5% population generates 60% health care cost 49% catastrophic- only 1 year of high cost 40% consistently high cost – chronic disease 11% costs are in the last year of life 3 Payer-Provider Partnerships: A Palliative Care Toolkit and Resource Guide, Center to Advance Palliative Care, 2014

4. Medical Management Keep the well from getting sick - prevention Handle acute illness efficiently and effectively Manage the chronically ill 4

5. Population Care (95% population, 40% cost) “Walking well” aka “young invincibles” –Healthy lifestyle (diet, exercise, substance avoidance) –Safe lifestyle (seatbelts, bike helmets) –Preventive medicine (chol, BP, mammogram) –Prenatal care (no alcohol, no smoking, folic acid) Acute illness (flu, broken bones, gastroenteritis, UTI) –Early intervention –Most cost effective site of care (PCP, UC) –Contracted provider (unit cost and utilization) –Quality care- do it right the first time 5

6. Population Care (5% population, 60% cost) Catastrophic illness (trauma, burns) –Contracted quality providers Chronic illness/ end of life –Disease management –Case management –Transition care management –Palliative care –Hospice –Behavioral health –Pharmacy 6

7. Health Net Programs State Health Program Case Mamagement Ambulatory Case Management (vendors)) Complex Case Mamagement (vendors0 Care transition (from the hospital) Behavioral Health Home infusion Pharmacy Disease Management (vendor) Concurrent Review (acute and skilled nursing) Prior authorization High risk OB Community resources In Home Support Services (State Health Programs) Palliative care Pain management 7

8. Medical Management Population management (public health) Disease prevalence (outbreaks) Prevention Broad recommendations for a healthier population Disease management Improvement for a specific disease Education, coaching, and intervention Activation Well enough to make a difference Sick enough to make a difference Intervention may require physician participation (e.g. CHF) Case management Managing the individual Socio-economic and medical Multifactorial, co-morbidities Transition care management From the in-patient setting to the out-patient setting (hospital discharge) Appts, meds, red flags, record End of life 8

9. Cost Containment Case Study END OF LIFE 9

10. 10 Barnato, AE, et al, Medical Care, 45: 386 – 393, May, 2007 40% concerned about too little treatment 45% concerned about too much treatment 86% prefer to be at home for last days 84% not want life prolonging drugs that make them feel worse 72% want symptom relief even if drugs may shorten life 87% would NOT want mechanical ventilation to prolong life by 1 week 77% would NOT want mechanical ventilation to prolong life by 1 month

11. High Risk Diagnoses – Cancer -NEJM Randomly assigned patients with metastatic lung cancer to receive either standard oncologic care or early palliative care, focused on symptom control and psychosocial support for patients and families, together with standard oncologic care. Patients receiving early palliative care had: – lower rates of depression – a better quality of life – better mood scores – fewer hospitalizations and emergency department visits – received less aggressive care at the end of life – had significantly longer survival than did patients receiving standard care alone (11.9 months compared to 8.9 months) Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung CancerEarly Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer. Temel J.S., Greer J.A., Muzikansky A., et al. N Engl J Med 2010; 363:733 - 742 11

12. 12 Medicare Expense in the Last 6 Months of Life Barnato, AE, et al, Medical Care, 45: 386 – 393, May, 2007 Grand Junction, COMcAllen, TX Hosp/physician cost$8,366$21,123 Days in ICU1.05.6 Died in acute hosp16.7%45.1% No correlation of cost with outcome or satisfaction No significant correlation of cost with patient preferences Cost is related to –More specialists –More hospitals and ICU beds –More technology

13. 13 Palliative Care Large regional variation in “death in hospital” vs “death in home” Death in home hospital nursing home Oregon35% 32%32% National25% 50%25% New York21% 62%17% Only 31% of late stage cancer patients had end of life discussion with oncologist

15. Where’s Waldo? Spend a lot money at end of life Regardless of patients’ wishes Which vary by zip code Variation based on number of specialists number of hospitals amount of technology available With physicians not discussing options with the patient WHAT SHALL WE DO? 15

16. Palliative Care Specialized medical care for people with serious illness. This type of care is focused on providing patients with relief from symptoms, pain, and stress from the serious illness – whatever the diagnosis. The goal is to improve quality of life for both the patient and family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient’s other doctors to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness and can be provided together with curative treatment. 16

17. Major Palliative Referral Criteria Utilization (using or about to use the hospital and ED to manage their condition) Code Status issues Diagnosis and prognosis (progressive with 1-2 years life expectancy Symptoms not controlled (pain, nausea and vomiting) Support needed (psychological, financial, social, caregivers High cost 17

18. Hospice Terminally ill - 6 month prognosis Comfort only, not curative Family caregivers can get extra support and benefits Medicare Hospice Benefits official government booklet 18 Palliative Care Curative and supportive Usually 12-24 month prognosis Usually not a benefit

19. Palliative Care Pilot (30 referrals) 3 refused 17 from Top 1% Team; 13 from direct referral 67% of deaths in the home (national aver. 25.4%) 40% to hospice 53% DNR as out patient 80% DNR in hospital 74% completed POLST 19

20. Palliative Pilot (cont’d) Mean time in hospice22.4 days (NHPCO aver. 72.6 days) Median time in hospice 8 days (NHPCO aver. 18.5 days) Average time in palliative program 22 days MD visits1.5 PMPM(budget 1.0) RN visits5.8 PMPM(budget 4.0) Phone calls26.2 PMPM(budget 20.0) 20

21. Opportunity Analysis Savings 36 acute hospital admits 13 acute hospital days 1 skilled nursing facility admit 730 subacute days 21 ambulance rises (911) $868,053 (although 1 case saved $396,664) 21

22. What Does the Data Tell Us? (aka “where’s the beef”) Highly successful on dollar savings Referrals are late in the course of illness (hospice data, time in palliative)- need more education/ marketing Low volume –57% from claims ; more data mining – other sources e.g. LTC, dialysis, oncology, ED UM reports –43% real time; more marketing, education –Low volume due to limited Medicare –Only one county (? expand) 10% refusals – avoid the “H” word and the “P” word Reimbursement insufficient relative to resources consumed (contract; telemedicine) 22

23. Dear Willie Populations are heterogeneous – not all banks are the same Different interventions for different subpopulations – not all banks are robbed in the same way Can measure the value proposition – that’s why you case the bank…the “take’ better be worth the risk It doesn’t work for every patient, but it works most of the time – I know it’s not perfect…explains why I got caught…but I thought it was worth it 23