Presentations text content in Population Health Management:
Slide1
Population Health Management:The Doctor is in_______________________
Michael Vincent Smith, MD FACC, FACS, FCCP RVP Medical Director Central Region, Medicare
COMPANY CONFIDENTIAL | FOR INTERNAL USE ONLY | DO NOT COPY
Slide23
0,000 French Soldiers: 8,000 English and Welsh Soldiers10,000 French Deaths: 112 English and Welsh DeathsHistorians attribute the decisive victory of the English against the overwhelming forces of the French to five crucial elements
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Understanding the Terrain
Adapting Tactics to the Situation
Optimal Use of Available Tools
Superior Teamwork
Mindful of the Treasure
Slide3Historians Attribute the Decisive Victory of the English Against the Overwhelming Forces
of the French to Five Crucial Elements 3
English and Welsh
French
Terrain
Henry notices that the road
has a narrowing and is soaked with mud from rain
French decide to block the
road hoping to goad the English into direct attackTacticsHenry moves his troops
forward so that advancing French lose mobilityHenry’s troop movement prevents the French from flanking the English army
TeamTrained, combat-tested soldiers united in loyalty to their warrior kingHastily assembled cadre of French men under the auspices of regional rulersTools6,400 longbows capable of lethality at 300 yards, eight arrows per minute, pikesBroadsword limited by proximity,
narrow space; heavy armor, a liability in mudTreasure
War reparations and heir to France throne vs. death or ransomRoyal succession not determined by outcome, defeat by English thought impossible
Slide4Pre-Affordable Care Act Population Health Terrain4
“It is to the hospital’s advantage to have beds full, so they are not compensated for providing well-care, and may do things they would not do with a different reimbursement structure.” NSLIJ CEO Michael Dowling, 2013“As a direct result of the serious funding challenges facing the MA program, the need is greater today than ever before for innovations that deliver increased value to beneficiaries with the increasingly limited resources that are available to support the MA program.”
Stephanie
Kanwit
, AHIP, 2014
Medically Necessary and Unavoidable
Not Medically Necessary and Avoidable
Acute or
chronic
inflammatory, ischemic, infectious, hemorrhagic, metabolic , behavioral or traumatic conditions where either the severity of the presentation or the intensity of the anticipated services necessary for the safe and effective evaluation and management of the condition warrants admission to an acute inpatient facility Acute or chronic inflammatory, ischemic, infectious, hemorrhagic, metabolic , behavioral or traumatic conditions where neither the severity of the presentation nor the intensity of the anticipated services necessary for the safe and effective evaluation and management of the condition warrants admission to an acute inpatient facility
Slide5Post-Affordable Care Act Population Health Terrain-VBC
5Not Medically Necessary
Should
not occur
Acute or chronic
i
nflammatory, ischemic, infectious, hemorrhagic, metabolic, behavioral or traumatic conditions where neither the severity of the presentation nor the intensity of the anticipated services necessary for the safe and effective evaluation and management of the condition warrants admission to an acute inpatient facility
Medically Necessary
Acute or chronic inflammatory, ischemic, infectious, hemorrhagic, metabolic, behavioral or traumatic conditions where either the severity of the presentation or the intensity of the anticipated services necessary for the safe and effective evaluation and management of the condition warrants admission to an acute inpatient facility
Acute or chronic
i
nflammatory, ischemic, Infectious, hemorrhagic, metabolic, behavioral or traumatic conditions where either the severity of the presentation or the intensity of the anticipated services necessary for the safe and effective evaluation and management of the condition warrants admission to an acute inpatient facility but that could have been prevented with better earlier management of the member’s condition
Unavoidable
A
voidable
Slide6The Changing Health Care TerrainPayment Model for Care Delivery has changed and is not going backCMS-50% of Medicare payments will be VBC by 2018Anthem-50% of Medicare VBC by 2016United-$65 B in VBC by 2018
Aetna and BCBS-75% VBC by 2020Humana- 75% MA in VBC by 2017Real collaboration between Payers, Providers and Care Delivery Systems in no longer a luxury but is instead a survival imperative that requires understanding the new terrain, adaptive tactics, experienced and innovative leadership, and superior tools to achieve clinical, operational and financial alignmentCOMPANY CONFIDENTIAL | FOR INTERNAL USE ONLY | DO NOT COPY
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Slide7Terrain-Inadequate
Integrated Health Care InfrastructureAgency for Healthcare Research and Quality 7
Quality of Hospital Care
Quality of Nursing Home Care
Quality of Home Health and Hospice Care
Quality of Ambulatory Care
Slide8ANNALS
OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 10, NO. 5 ✦ SEPTEMBER/OCTOBER 2012 396
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Terrain –
2015 Inefficient use of Physician Resources
Estimates suggest that a primary care physician would spend
21.7
hours per day
providing
all recommended acute,
chronic
and preventive care for a panel of 2,500
patients. The average U.S. panel size is about 2,300.The FFS model is designed for episodic treatment and not chronic care management Patients receive only 55%
of recommended chronic and preventive services
About one-half of U.S. adults have at least one chronic condition
50%
of people with hypertension have uncontrolled blood pressures
More than
80%
of people with hyperlipidemia have not attained cholesterol control
43%
of people
diagnosed with diabetes
have not achieved glycemic control
Slide9Terrain-MEDPAR data Cleveland Clinic Health System [
Even the best hospitals know the model has changed]COMPANY CONFIDENTIAL | FOR INTERNAL USE ONLY | DO NOT COPYFinancial Statistics
$
%
Gross Patient Revenue
12,751,708,196
93.5
Non-Patient Revenue
890,597,907
6.5Total Revenue13,642,306,103
Net Income (or Loss)
646,121,222 4.7
Slide10Terrain: Chasing the shiny objects
Higher Lower
MD Longitudinal Efficiency Index
(total cost per case mix-adjusted treatment episode)
Low Quality
High
TCOC
(Nightmare
Providers
)
MD Quality Index
(outcomes or % adherence to EBM)
High Quality
Low
TCOC
(Dream
Providers)
Low Quality
Low
TCOC
High Quality
High
TCOC
Lower Higher
50th %
ile
50th %ile
Adapted from Regence Blue Shield
2003 A. Milstein MD
Slide11
Terrain-The NEW Essentials for Building Competitive Integrated Health Delivery Systems
COMPANY CONFIDENTIAL | FOR INTERNAL USE ONLY | DO NOT COPYPopulation Health systems that manage across the continuum of care (medical and behavioral, inpatient and outpatient, acute and chronic)Allocating Resources in a manner that nurtures clinical, operational and financial alignment of patients, providers and payers
Provider directed care coordinated products with Superior Functionality, Reliability, Convenience and Pricing
Slide12
RAF
Medical Expense Ratio is optimized by:
Identifying and documenting burden of illness
Utilizing evidence-based guidelines to drive prevention, early detection, wellness and superior management of chronic illness
Improving resource allocation to optimize member experience while lowering total cost of care
2.0%4.5Stars
Total
CoC Reduction1.50.95
3.60%
4.01.251.0%
The Tactics for Success in PHM – Progressively Enhance Revenue and Simultaneously Lower Costs
12
0.95
1.0
1.1
5.0
1.2
4
.0%
It is Anthem’s goal to provide quality, cost-effective health care benefits to its members and customers. In doing so, Anthem uses the phrase “Cost of Care” to refer to programs and initiatives intended to meet this goal. Anthem does not compensate, reward or incent associates, financially or otherwise, for restricting benefit coverage or for denying coverage for medically necessary health care benefits.
Slide13Team-Population
Health’s Core 25
Sub-Acute
Inpatient
Rehabilitation
Independent
PCP and Specialty Care
Adult
Day
Care
Senior
Wellness
Programs
Member
Stratification and Segmentation
Annual Wellness
Assessment
Care
Management
Services
Ambulatory Intensive
Care
Social Services
Collaborations
Assisted
Living
Care
Ancillary Services
(Outpatient
Dialysis/DME
)
Medical
Therapeutic
Management
Hospital PCP
and Specialty Care
Home
Health
Care
Intensive
Care
Transitional
Care
Unit
Post
Acute
Care
Caregiver
Support
Skilled
Dementia
Nursing Care
Skilled
Nursing
Care
Urgent
Care
Center
Emergency
Room
Acute
Inpatient
Rehabilitation
Acute
Inpatient
Behavioral
Acute
Inpatient Medical
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Slide14Team-Population
Health’s Core
25-
True Integration
Sub-Acute
Inpatient
Rehabilitation
Independent
PCP and Specialty Care
Adult
Day
Care
Senior
Wellness
Programs
Member
Stratification and Segmentation
Annual Wellness
Assessment
Care
Management
Services
Ambulatory Intensive
Care
Social Services
Collaborations
Assisted
Living
Care
Ancillary Services
(Outpatient
Dialysis/DME
)
Medical
Therapeutic
Management
Hospital PCP
and Specialty Care
Home
Health
Care
Intensive
Care
Transitional
Care
Unit
Post
Acute
Care
Caregiver
Support
Skilled
Dementia
Nursing Care
Skilled
Nursing
Care
Urgent
Care
Center
Emergency
Room
Acute
Inpatient
Rehabilitation
Acute
Inpatient
Behavioral
Acute
Inpatient Medical
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Established Engagement Structure
Operational Processes Documented
Key Performance Indicators Tracked
Data Sharing Mechanisms Defined
Slide15“The Institutionalization of leadership training is one of the key attributes of good leadership” –John Kotter, Harvard Business School15
“The Population Health Management Playbook”
Volumes
Clinical Alignment, Operational Alignment, Financial Alignment
Sections
Payers, Providers, Personnel, Patients
Topics
Evaluation, Engagement, Education, Empowerment,
Excitement, Re-Evaluation ChaptersTerrain (SWOT), Tactics (Strategies), Teams (RACI), Tools (Resources), Treasure (KPI)
Slide16
Complex Care Management, Palliative/Hospice
Complex Care Management,
Independence at Home
Complex Care
Management, Gap Closures
Screening, Secondary Prevention
Member Education, Shared Decision Making
20%
30%
30%
15%
5%
20%
80%
Tools-20% of the member population drives 80% 0f the costs (Unhealthy); includes the Frail 5% that drive 50%
Slide17COMPANY CONFIDENTIAL | FOR INTERNAL USE ONLY | DO NOT COPY
Evaluation and Management Tools to improve care, eliminate Denial Management for Acute Episodes of Treatment [CDSS]
Slide18Treasure: Proactive Multidisciplinary Team-Driven Member Evaluation, Segmentation, Engagement, Management and Monitoring
Slide19Mindful of the TreasureThere will be 70,000,000 Seniors in the U.S. by 2030
Anthem will be a preferred partner of high performing Health Delivery Systems for this populationBy engaging and educating providers on the new world of health care and empowering them to standardized care delivery practices and processes in ways that improve quality and lower cost We are seeking partners with the desire and capacity to develop High Value Clinically Integrated
M
edical
M
anagement
I
nfrastructures capable of delivering outstanding patient experience with clinical quality, superior access and lower cost
…that can be financially competitive in a risk bearing environment
Slide20Questions?
http://openeducationchallenge.eu/sites/default/files/field/image/equation.PNGCOMPANY CONFIDENTIAL | FOR INTERNAL USE ONLY | DO NOT COPY20
Slide21
Population Health Management:
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