1. Population Health Management: Technical & Analytical Considerations
Mike Soltis
8.4.17

2. Spectrum Health & Population Health Management
Some initiatives and programs
Enable initiatives, programs, and strategy through technology and Analytics
What does success look like?

3. Initiatives and Programs
Comprehensive Primary Care Plus (CPC+)
Attribution/Empanelment
Clinical Excellence Council
Social determinants of health

4. What is CPC+
Comprehensive Primary Care Plus (CPC+) is an advanced medical home model via CMS under which primary care practices can be reimbursed.
5-year model beginning in January 2017

5. CPC+ Driver Diagram
The Driver Diagram (see Figure 1)illustrates how all components of the CPC+ model work together to support your practice in the delivery of comprehensive primary care. At the center is what we are striving to do: to achieve better care, to improve health outcomes, and to be smarter about how we spend money for patients and families. In the Driver Diagram, the primary driver, Comprehensive Primary Care Functions (in blue), are supported by three foundational drivers: Use of Enhanced, Accountable Payment (in green); Continuous Improvement Driven by Data (in orange); and Optimal Use of Health IT (in red). Supporting this Figure 1: Driver Diagram entire primary care practice model is Aligned Payment Reform (in purple) in which commercial and state payers partner with the Centers for Medicare & Medicaid Services (CMS) by providing care management fees and performance-based incentive payments. For Track 2 practices, Aligned Payment Reform provides additional flexibility by shifting a portion of your fee-for-service (FFS) payment and adding an upfront Comprehensive Primary Care Payment (provided by Medicare). Partner payers have also committed to offer an alternative to FFS payment.

6. Stepwise Analysis Understand our patient population
By risk tier (for example)
Understand risk scores across sites
Variation in scores across sites?
Identify changes in risk tiers
Why do some tier 5 patients have low risk scores?
Did any new patients appear in any of the tiers?
Did any patients disappear or move between tiers? If so, why?  Further investigation needs to be done for new tier 5 patients (high PMPM)

7. Stepwise Analysis Continued…
Explore utilization
What does the data tell us about inpatient admissions?
What does the data tell us about ED visits? ACSC ED visits?
Identify Quality improvement opportunities
Relationship between high utilization and gap closure?
Cost
Relationship between cost and risk tiers? Cost and risk scores?

8. Analysis into Action
There are sites with nearly 50% of patients in tier 5.
Of these, only one appears in the top 5 admission rates – the others are about average in Admits and ED rates/1000
At the site level, there is no correlation of
overall risk score and admissions/1000
risk and overall PMPM
risk and tier 5 PMPM
admissions/1000 and overall PMPM

9. Initiatives and Programs
Comprehensive Primary Care Plus (CPC+)
Attribution/Empanelment
Technical capabilities
Attribution algorithm
Clinical Excellence Council
Social determinants of health

11. Initiatives and Programs
Comprehensive Primary Care Plus (CPC+)
Attribution/Empanelment
Clinical Excellence Council
Social determinants of health

12. Clinical Excellence Council (CEC)

13. Initiatives and Programs
Comprehensive Primary Care Plus (CPC+)
Attribution/Empanelment
Clinical Excellence Council
Social determinants of health

14. Social Determinants of Health
By Sept 2017 the following will be in place:
All patients engaged with care management will be screened for social determinants.
Standard work for screening for social determinants on care managed patients will be developed.
Flowsheet within Epic for capture of CPC+ domain requirements will be deployed within Epic.
Reports will be developed to assess how we are doing on screening of engaged care management

15. Technical Enablers ADT John’s Hopkins ACG Healthy Planet (Epic)
Roster Management Engine (Epic)
Caboodle (DW) claims integration

16. Success?

17. What else?
Questions
Feedback
Thoughts?