Population Health Management: PowerPoint Presentation, PPT - DocSlides

Population Health Management:The Doctor is in_______________________

Michael Vincent Smith, MD FACC, FACS, FCCP RVP Medical Director Central Region, Medicare

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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

Historians 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

Pre-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

Post-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

The 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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Terrain-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

ANNALS

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

Terrain-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

Terrain: 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

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

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

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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.

Team-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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Team-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

“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)

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%

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Evaluation and Management Tools to improve care, eliminate Denial Management for Acute Episodes of Treatment [CDSS]

Treasure: Proactive Multidisciplinary Team-Driven Member Evaluation, Segmentation, Engagement, Management and Monitoring

Mindful 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

Questions?

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