Innovations In Health Care Delivery Tuesday, March 8, 2011 W Hotel Washington Washington, DC Susan Dentzer Editor-in-Chief Health Affairs.

Innovations In Health Care DeliveryTuesday, March 8, 2011W Hotel WashingtonWashington, DC

Susan DentzerEditor-in-ChiefHealth Affairs

Health Affairs thanks these organizations for their support of today’s briefing and the “Innovation Profiles” featured in the March 2011 issue of the journal:

David Blumenthal, M.D., M.P.P.National Coordinator for Health ITU.S. Department of Health and Human Services

Innovations in Health Care Delivery: From Patchwork to Quilt

Anne-Marie J. Audet, MD, MScVP Health System Quality and Efficiency

ProgramThe Commonwealth Fund

Defining our Terms:Innovation• From Latin Innovatus, Innovare :“To renew or change,"

from in- "into" + novus "new".

• Innovation can therefore be seen as the process that renews something that exists and not, as is commonly assumed, the introduction of something new.

High Performance Health System Attributes and Functionalities* • Patients' clinically relevant information is available to all providers at the point of care and to patients through electronic health record systems.

• Patient care is coordinated among multiple providers, and transitions across care settings are actively managed.

• Providers (including nurses and other members of care teams) both within and across settings have accountability to each other, review each other's work, and collaborate to reliably deliver high-quality, high-value care.

• Patients have easy access to appropriate care and information including after hours; there are multiple points of entry to the system; and providers are culturally competent and responsive to patients' needs.

• There is clear accountability for the total care of patients.• The system is continuously innovating and learning in order to

improve the quality, value, and patients' experiences of health care delivery.

Source: A. Shih, K. Davis, S. Schoenbaum, A. Gauthier, R. Nuzum, and D. McCarthy, Organizing the U.S. Health Care Delivery System for High Performance, The Commonwealth Fund, August 2008

Common Themes• Convenience sample• Variety of settings (context)

– Health Systems, Health Plans, Hospitals, Physician Networks, FQHCs, Professional Societies, States

• Assessment according to logic model of change (Prochaska Behavioral Model)

– Knowledge of problem: A+++++– Tools (innovations): B– Motivation (Incentives, Will): F

Common Themes

• Identify, know, segment and ongoing close engagement with population (McLuhan’s “The medium (cold vs hot) is the message”)

• Prioritize primary and preventive care – health and healthcare

• Multi-disciplinary , accountable team care • Performance improvement infrastructure• Maneuver within payment and regulatory environment• Evolutionary process of change over time (4 or more

years)• Urgent need for data about impact on Three Part Aim

Ears to the Ground: Know Thy Population and Standardize Person Tailoring• Jo-Ann Lynn’s Bridges to Health Model (young healthy, disabled, stable

chronic conditions, unstable, end-of-life)• Innovations and programs tailored to prevalence of disease, disease

burden• Segment - high need, low need• Standardized tailoring

– Bellin’s pyramid access cascade model • MyChart patient portal• Community-based His Health and Her Health programs• Employer-based clinics• Fast Care Clinics – retail

– Cambridge Health Alliance – MyChart (parents and kids); high touch-low touch segmentation

– Clinica Family Health Services (CO)- people measure their own BP at time of visit

• Open door philosophy, connect to population – often and variety of methods

10

9789 89

78 77

54 5450

4338

29

0

25

50

75

100

NET NZ UK FR ITA GER SWE AUS CAN NOR US

Practice Has Arrangement for Patients’ After-Hours Care to See Doctor/Nurse

Percent

Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

11

Percent AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US

Has e-mailed medical question to regular doctor or place of care in past two years

2 4 2 7 2 4 4 6 3 9 6

Can make an appointment via e-mail or Web site at regular place of care

7 6 9 60 10 9 23 13 13 25 15

Online Access at Regular Place of Care

Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.

Base: Has regular doctor/place of care.

Accountable Care Teams• All sites profiled created multidisciplinary teams • Accountability at core of team supported by IT to

allow just-in-time sharing of information around an entire care plan

– Aurora Acute Care for Elder Tracker on E-Geriatrician– Cambridge Health Alliance registry shared by all providers,

school based clinics, community-based health workers– GRACE: web-based care plan shared by NP, SW, geriatrician,

pharmacist, PT, community resource expert

• Need for more robust data on cost of these models of care

– VT Community Health Teams – 5 FTEs serve 20K population; $350K per year

– Martin’s Point teams went from 4.3 employee per MD to 6 per MD

– Healthcare Partners – Comprehensive Care Center Program saves $3,500 per hospital day avoided, redirected to support program

98 9891 88 88

73 73

59

11

5254

0

25

50

75

100

SWE UK NET AUS NZ GER NOR US ITA CAN FR

Practices Use Nonphysician Clinical Staff for Patient Care

Percent reporting practice shares responsibility for managing care, including nurses, medical assistants

Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

Primary Care is Really Prime

• Primary care as core value and expected outcome is health not just health care

• But this entails “system” approach for cross continuum care services

– New business model for acute care settings– Successful systems are able to align financial incentives

• Mercy Health System working with Keystone Mercy Health Plan• HealthCare Partners Medical Group - partial or full risk capitation

• Clinica Family Health Services costs per visit $167, Medicaid pays $155

• Performance improvement infrastructure to support practice

– Healthcare Partners Medical Group (CA, NE, Fl): “Comprehensive Care Center Program – teams concentrate on stabilizing patients and supports MD practices in taking care of more patients with more intense needs post discharged (45min vs 15 min visits)

– VT ITE – Blueprint Central Registry; training practices; web of connection (e.g. heat assistance->medical home referral)

– GRACE model – home assessment team– Shared services models (TA, workforce): private/public support

Extrinsic Motivation • Examples of financial models:

– FFS + PMPM Medical Home Supplement– Risk sharing:

• Risk-adjusted capitation

• Global payment

• Consistent evidence of barriers to innovations: antiquated payment methods and regulations– Successful systems able to move away from volume and

service-based payment – Balanced payment models that includes rewards based on

quality and efficiency– Allows flexibility in care design– FFS environment prohibitive to sustainability and spread

of innovations

• Professionalism, recertification, professional boards (e.g.

AAP)

16

Financial Incentives and Targeted Support

Percent can receive financial incentives* for:

AUS CAN FR GER ITA NET NZ NOR SWE UK USHigh patient satisfaction ratings

29 1 2 4 19 4 2 1 4 49 19

Achieving clinical care targets

25 21 6 6 51 23 74 1 5 84 28

Managing patients w/ chronic disease or complex needs

53 54 42 48 56 61 55 9 2 82 17

Enhanced preventive care activities**

28 26 14 23 28 17 38 12 2 37 10

Adding non-physician clinicians to practice

38 21 3 17 44 60 19 7 2 26 6

Non-face-to-face interactions with patients

10 16 3 7 *** 35 5 30 4 17 7

* Including bonuses, special payments, higher fees, or reimbursements. ** Including patient counseling or group visits. *** Question not asked in Italy survey.Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

From Patchwork to Quilt: Spreading Success Local to National One Community at a Time?

• Boom Towns• Evangelical Epicenters• Military Bastions• Service Worker Centers• Campus and Careers• Immigration Nation

• Minority Central• Tractor Community• Mormon Outposts• Emptying Nests• Industrial Metropolises• Monied Burbs

• What is the typology of communities, regions underlying health care system spread strategies? Geography is not sufficient, market characteristics are important, what are other determinants that will be key to spread?

• Patchwork America Project illustrates subtle, yet significant differences among communities in the US, that affect numerous cultural, political, consumer behaviors. Do these also affect behaviors related to health and health care?

Learning In Order to Spread and Get Results

• Strategy to identify promising innovations• Pawson and Tilley’s approach: emphasize the “why” and not only the

“what” works or does not work – “Experimentalists have pursued too single-mindedly the question of

whether a social program works at the expense of knowing why it works.”

– CMO vs OXO approach • Criteria to determine whether the innovation is worth evaluating with

goal of spread– Flexibility of adoption in various settings– Requirements for effective adoption

• How much disruption will be entailed • Need for regulatory or other significant changes to allow spread

• Not every innovation will succeed– How much are we willing to spend – ROI (20% in technology)

From Patchwork to Quilt: What is on the Horizon

• Payment reform (2003 Leatherman et al HA paper Business Case for Quality) – now a reality

• Workforce – National Health Care Workforce Commission; Funding for Title VII and Title VIII programs to educate and train primary care physicians and other health professionals

• Innovation and improvement infrastructure (RECs, QIOs, etc)

• Data needs – more timely, all payers

• Longer term horizon for impact with short term expected targets

• CMMI – promising programs– Mission to identify, validate and scale models that have been effective in achieving

better outcomes, but may be relatively unknown.– Eight States selected to participate in the Multi-Payer Advanced Primary Care – Federally Qualified Health Center (FQHC) Advanced Primary Care Practice

Demonstration will evaluate the impact of this care model on access, quality and cost of care provided to low-income beneficiaries served by these facilities

Christopher A. Langston, Ph.D.Program DirectorThe John A. Hartford Foundation

Sean Cavanaugh Director, Provider Contracting and Reimbursement, Center for Medicare and Medicaid Innovation, U.S. Department of Health and Human Services

Reflections on Innovation

David N. Gans, MSHA, FACMPEVice President, Innovation and ResearchMedical Group Management Association

Reflections On the Articles• Patient-centered care reduces the total

cost of services, while improving quality and patient satisfaction.

• Savings come from fewer ED visits, less hospital admissions, and shorter lengths of stay, but . . .

• With increased expenses to the provider due to increased staff, the application of new technologies, and having to re-engineer workflow.

Key Themes in Innovation and Health Care Delivery• Change is not easy.• Care plans often combine clinical

treatment with “Lifestyle Medicine” –managing the patient’s nutrition, stress, and activity level to improve total health status.

• Fee-for-service payment does not necessarily consider the costs associated with these innovations.

Increased Administrative Complexity Must Be Addressed • Quality and performance measures are

unique to each insurance payer and need to be standardized

• Practice management systems do not fully support data reporting

• The “Patient Centered Medical Home” has three different organizations setting requirements: the NCQA, AAAHC, and the Joint Commission

A Final Thought on Innovation in Care Delivery

We are confronted with insurmountable opportunities.

  - Walt Kelly

Neil S. Fleming, Ph.D., C.Q.E.Vice President, Health Care ResearchBaylor Health Care SystemDallas, Texas, USA

Study Authors: Fleming NS, Becker ER, Culler SD, McCorkle, R, and Ballard, DJ

Contact: [email protected]

The Financial and Nonfinancial Costs of Implementing Electronic Health Records in Primary Care Practices

Study Description

• Funded by: Agency for Healthcare Research and Quality R-03 grant

• Purpose: To quantify the financial and nonfinancial (time and effort) costs of electronic health records (EHRs) in primary care practices to inform stakeholders

• Setting: 26 HealthTexas primary care practices as part of the Baylor Health Care System, (in North Texas) implementing the electronic health record between June 2006 and December 2008, tracking 120 days prior to launch and 60 days after

• Methods: interviews with key personnel, documents, calendars, e-mails, and payroll information

• Study groups: HealthTexas network implementation team, practice implementation team, and end-users with diverse skills and expertise that are carefully coordinated

Results Time and effort are non-financial costs

Network implementation team expends 480.5 hours and $28k per practice

Practice implementation team expends 130 hours and $7,857

End-users expend 134.3 hours and $10,325 per physician

Hardware costs: one-time infrastructure purchases are $25k per practice and $7k per physician

Software and maintenance costs: licensing, hosting, networking, and technical support for first 60 days are $2,850 and $17,100 per year

Total costs: $32,409 per physician and $162,047 in a 5-physician group from launch through first 60 days

Conclusions

Financial Alignment is needed between those stakeholders paying for EHRs and those receiving potential benefits

Some economies of scale can be achieved with larger practices due to variable nature of some costs

Strategies are needed to support and coordinate the diverse set of medical and technical skills required to ensure successful implementation of EHRs and physician satisfaction

More Than Four In Five Office-Based Physicians Could Qualify For Federal Electronic HealthRecord Incentives

Brian Bruen,1 Leighton Ku,1

Matthew Burke,2 and Melinda Buntin2

1 George Washington University2 Office of the National Coordinator for Health Information Technology

NOTE: Commentary is the authors’ opinion and does not necessarily reflect the views of the Office of the National Coordinator for Health Information Technology.

HITECH Incentives• To qualify:

– Any Medicare patients– At least 30% Medicaid patient

volume• More lenient criteria for pediatricians,

also clinicians in community health centers and rural health clinics

• Must demonstrate “meaningful use” of certified EHR technology

• Get Medicare OR Medicaid, not both

Office-Based Physicians Potentially Eligible For HITECH Incentives And Using Electronic

Health Records (EHRs), 2007–08Not eligible for incentives, does not have basic EHR,

14.6%Not eligible for incen-

tives, already has basic EHR, 2.8%

Eligible for incen-tives, already has basic EHR, 12.1%

Eligible for incentives, does not have basic EHR, 70.5%

SOURCE Authors’ calculations based on combined 2007–08 National Ambulatory Medical Care Surveys. NOTE HITECH is Health Information Technology for Economic and Clinical Health.

Highlights from Findings• Incentives should greatly

accelerate use of electronic health records– 4 out of 5 office-based physicians

could qualify, if they achieve meaningful use

• Incentives are well-targeted, but certain groups of physicians are more likely to be excluded– pediatricians, psychiatrists,

obstetrician-gynecologists

Policy Responses• Monitor gaps in eligibility, use• Pro-rate eligibility for Medicaid

incentives• Assist solo practitioners, smaller

practices in adopting systems and achieving meaningful use– Government (e.g., ONC) and private

roles (e.g., insurers, foundations)

The Benefits of Health Information Technology: A Review Of The Recent Literature Shows Predominantly Positive Results

Melinda Beeuwkes BuntinDirector, Office of Economic Analysis, Evaluation and Modeling, Office of the National Coordinator, U.S. Department of Health and Human Services

Director, Office of Economic Analysis, Evaluation and Modeling, Office of the National Coordinator, U.S. Department of Health and Human Services

Purpose• To update policy makers,

innovators, health IT users, and those contemplating adoption about health IT’s effects on care delivery and provider and patient satisfaction

Methodology• Used framework from two previous

reviews (Chaudhry et al. 2006 and Goldzweig et al. 2009), to identify health IT literature from July 2007 up to February 2010.

• For inclusion, an article must• address a relevant aspect of health IT• examine its use in clinical practice• include quantitative or qualitative

outcomes

Article Flow

Outcomes Addressed and Conclusions Reached

Findings • Over 92 percent of the studies reached

conclusions that were generally positive.

• Studies emerging from traditional health IT leaders (e.g. Kaiser, the VA) are no more robust in their study design or positive in their conclusions

• Studies examining provider satisfaction are more likely to have negative findings.

How the Affordable Care Act Can Help Move States Toward A High-Performing

System of Long-Term Services and Supports

By Susan C. Reinhard, Enid Kassner and Ari Houser

March 8, 2011

43

Characteristics of a High-Performing LTSS System

• Support for Family Caregivers• Ease of Access and Affordability• Choice of Settings and Providers• Quality of Care and Life• Effective Transitions and Organization of Care

44

State LTSS Scorecard

• States will be ranked on five dimensions that approximate the five characteristics of a high-performing LTSS System.

• Scorecard will call attention to state variation and put each state’s performance into context.

• Scorecard will provide a mechanism to track progress in years to come.

45

High Performing

LTSS system

is composed of

characteristics of a high performing LTSS system

that are approximated in the Scorecard by

dimensions based on available data

each of which is constructed from

Individual indicators that are interpretable and show variation across states

Creating a State LTSS Scorecard

46

The Affordable Care Act’s Role

• Offer States “Carrots” to Support Improvements in their LTSS Systems

• Balance Types of Services• Establish a Singe Point of Entry• Improve Coordination and Transitions

47

ACA Opportunities to Promote Scorecard Measures• Ease of Access:

– Expanding Aging and Disability Resource Centers– Balancing Incentives Payment Program

• Choice of Settings:– Community First Choice– Money Follows the Person

Palliative Care Consultation Teams Cut Hospital Costs For Medicaid Beneficiaries

R. Sean Morrison, Jessica Dietrich, Susan Ladwig, Timothy Quill, Joseph Sacco,John Tangeman, Diane E. Meier

Mount Sinai School of Medicine (New York)Center to Advance Palliative Care (New York)National Palliative Care Research Center (New York), University of Rochester Medical Center (Rochester),Bronx-Lebanon Hospital (New York)Center for Hospice and Palliative Care (Cheektowaga)

Background• Patients with serious or life-threatening illness

account for a disproportionately large amount of Medicaid spending

• Palliative care, when provided alongside disease directed care, has been shown to reduce symptoms, improve quality of life, reduce family burden, and prolong survival

• This study was performed to examine the effect of palliative care teams on hospital costs for Medicaid beneficiaries

Palliative Care: A Definition

Interdisciplinary specialty that aims to relieve suffering and improve quality of life for patients with advanced illness and their families.

Palliative care is provided simultaneously with all other appropriate medical treatment.

Distinct from hospice care which is medical care toward the end of life devoted exclusively to palliation

As Illness Progresses…An Increasing Emphasis on Palliation

Methods• Retrospective analysis of hospital

administrative and cost-accounting data• Sites: Four structurally diverse urban New

York State hospitals in one large and two mid-size cities

• All sites had mature palliative care consultation teams

• Adult Medicaid beneficiaries with advanced illness receiving palliative care were matched by propensity score to usual care patients

• Calendar years 2004-2007• GLM and multivariable logistic regression

models used to analyse results

Palliative Care and Cost Outcomes

*P<.05, † P<.01 ‡P<.001. N/A = not applicable

Cost/Day For Patients Discharged Alive

Implications• Hospital costs among Medicaid beneficiaries were

significantly lower when they had consultations with the palliative care team

• Palliative care team consultations may reduce expenditures, while helping to ensure quality care consistent with patient wishes, for hospitalized Medicaid beneficiaries.

• New payment mechanisms aimed at improving quality and efficiency would benefit from inclusion of palliative care teams.

Health Affairs thanks these organizations for their support of today’s briefing and the “Innovation Profiles” featured in the March 2011 issue of the journal: