Key Principles and Approaches to Populaiton Health mManagement - HAS Session 21

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Sreekanth Chaguturu, MD Vice President for Population Health Management, Partners HealthCare

Session #21 Key Principles and Approaches to PHM

Dr. Sreekanth Chaguturu is Vice President for Population Health Management at Partners HealthCare. He provides clinical oversight to population health management clinical programs, assists in management of clinical relationships for risk contracts with commercial and government payers, as well as oversight for Partners’ self-insured health plan. In these roles, he leads the assessment and development of information technology and analytic solutions to support population health programs.Dr. Chaguturu is also an Instructor in Internal Medicine at the Harvard Medical School and an attending physician at Massachusetts General Hospital.

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Greg Spencer, MD Chief Medical & Chief Medical Information Officer, Crystal Run Healthcare

Dr. Greg Spencer is the Chief Medical Officer and Chief Clinical Information Officer at Crystal Run Healthcare. He graduated from the Medical College of Wisconsin and completed residency training in Internal Medicine at Wilford Hall US Air Force Medical Center in San Antonio, TX, where he was chief resident and assistant director of the Internal Medicine Residency program and attained the rank of major. He is board certified in Internal Medicine and a Fellow of the American College of Physicians.

Dr. David A. Burton is the former Executive Chairman and CEO of Health Catalyst, and currently serves as a Senior Vice President, future product strategy. Before his first retirement, Dr. Burton served in a variety of executive positions in his 23-year career at Intermountain Healthcare, including founding Intermountain’s managed care plans and serving as a Senior Vice President and member of the Executive Committee. He holds an MD from Columbia University, did residency training in internal medicine at Massachusetts General Hospital and was board certified in Emergency Medicine.

David A. Burton, MD Former Chairman and CEO, Health Catalyst, Former Senior Executive, Intermountain Healthcare

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Poll Questions (1-3)Does your organization sponsor or participate in a population health management/shared accountability initiative (e.g., ACO or commercial)a. Yesb. Noc. Not sured. Not applicable

What percent of your patients are covered by your organization’s population health/shared accountability initiative?a) Less than 5%b) 5-10%c) More than 10%d) No ideae) Not applicable

In your opinion, how successful has your organization’s population health/shared accountability initiative been to date?f) Not at all successfulg) Slightly successfulh) Somewhat successfuli) Successfulj) Very successfulk) Unsure or not applicable

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Gregory Spencer MD FACPChief Medical Officer

Crystal Run Healthcare

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Our Approach

• Triple Aim as an organizational outline

Better care, better health, lower cost

• Analytics: multisource, scalable platform

• Provider involvement

• Care managers, CARETEAM, Telehealth

• Monitor the data

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NY Healthcare Environment

• Massive consolidation and mergers

• Bankruptcies

• Larger systems and groups

• Optum

• Venture capital

• Mostly unmanaged

• Urgent care centers and retail medicine

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Crystal Run Healthcare

Physician owned MSG in NY State, founded 1996

300+ providers, 20 locations

Joint Venture ASC, Urgent Care, Diagnostic Imaging, Sleep Center, High Complexity Lab, Pathology

Early adopter EHR (NextGen®) 1999

Accredited by Joint Commission 2006

Level 3 NCQA PCMH Recognition 2009, 2012

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Crystal Run Healthcare ACO

• Single entity ACO

• April 2012: MSSP participant

• December 2012: NCQA ACO Accreditation

• 35,000 commercial lives at risk

• MSSP

11,000 attributed beneficiaries

82% primary care services within ACO

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Business Intelligence Past

• Initially BI = business only, reports

• Quality, safety measures and clinical performance later

• Basic tools: SQL, SSRS, Excel

• Manual and time consuming

• Report generation > analysis

• Lack of scalability and extensibility

• Mostly tabular / numeric

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Dashboards

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Business Intelligence Now

• Central EDW- many sources, fewer joins

• Scalable

• More analysis, less reporting

• Self-service and drill down

• Consume and deliver information

• Visual

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Basic System Needs

• Common integrative platform

Pull together disparate data

• Cost: claims where available, internal costs

• A way to implement change

• “Leakage” and network

Where are patients going, are needs being met?

• Lean

Waste reduction, everywhere

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How we chose our EDW

• Our bias: controlled by us

• Avoiding “black boxes”

• Prior healthcare experience

• Modern technology

• Established track record

• Teach us how to fish

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Crystal Run EDW Roadmap

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Improving the patient experience

• Web Portal

• Care Managers

• Shadow Coaching

• Choosing Wisely

• Practicing Excellence

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Variation Reduction

• Specialty and division sponsored

Best practice review

Buy-in at the physician level

• Provider projects

Innovation contest

• National: Choosing Wisely

• Improved access - backfill and market share

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Variation Reduction

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Variation Reduction Improves Access

• 41,823 fewer visits

• 30,206 more patients

• “Created” 12 physicians

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Reducing Pharmaceutical CostsPEG Filgrastrim cost per patient before and after breast cancer pathway

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Total cost difference(equalized as cost per patient treated)

2012 pre-pathway

791 patients

$595,920

2013 post-pathway

817 patients

$368,160

TOTAL COST SAVINGS $227, 760

PEG-filgrastim use in Breast cancer patients

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Summary

• Triple Aim, core values as a guide

• Unified analytics platform that integrates disparate systems is required

• Quality, safety and performance programs that are tracked

• Physician involvement, variation reduction

• Patient experience

• Leakage, where and why

• Systematically find and reduce waste

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Sreekanth Chagaturu, MDMedical Director for Population Health Management

Partners HealthCare

Division of Population Health Management

September, 2014

Chapter 2: Innovations in Population Health Management

Sree Chaguturu, MDVice President, Population Health Management, Partners Health Care

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My goals for today

• Describe Massachusetts health reform efforts

• Provide overview of Partners Healthcare • Review select programs

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Patient Protection and Affordable Care Act

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My fair city…

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Chapter 58 of the Acts of 2006: An Act Providing Access to Affordable, Quality, Accountable Health Care

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Increasing health care spend in Mass crowded out all other areas

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Health care reform part two

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Who We Are: Partners HealthCare

• Massachusetts General Hospital• Brigham and Women’s HospitalTeaching Hospitals

• Newton Wellesley Hospital• North Shore Medical Center • Martha’s Vineyard and Nantucket Hospitals

Community Hospitals

• Spaulding Rehabilitation NetworkNon Acute Care

• McLean HospitalMental Health Care

• Partners Community Health Care• Community Health Centers

Community Provider Network

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Towns With PCHI Primary Care Care Physician Practices

MGH

McLean

Salem & Shaughnessy Kaplan

Union

BWHFaulkner

Newton-Wellesley

Spaulding

Partners Acute Hospitals

Partners Specialty Hospitals

RHCI

Partners Home Care Branches

Partners HealthCare across eastern Massachusetts

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Our Employees• ~60K employees – the largest non-government employer in the

state• ~13K are MDs, RNs and direct care givers• ~5K are primarily involved in research

Our Patients• ~1.6M ambulatory visits• ~168K discharges• ~4K licensed beds• ~$205M investment in community benefits

Teaching• 28 residency programs provide training to ~1,400 residents• ~$ 167M investment in teaching

Clinical Research• ~$1.6B in academic/research revenue • ~2,800 paid researchers (MDs & PhDs)

What we do

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Partners currently covers over 500,000 lives in an accountable care contract

Medicare Commercial Self Insured

•Example: Pioneer ACO

•Covered lives: ~74k

•Example: Alternative Quality Contract

•Covered lives: ~350K

•Example: Partners Plus

•Covered lives: ~100k

Medicaid

•Example: NHP

•Covered lives: ~30k

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Partners is implementing over a dozen PHM Programs

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Primary Care •Patient Centered Medical Home (PCMH) •High risk care management (palliative care) •Mental health integration •Virtual visits

Specialty Care •Active referral management (eConsults/curbsides)•Virtual visits• Procedural decision support (appropriateness)•Patient reported outcomes •Episodes of care (bundles)

Care Continuum •SNF care improvement (network/waiver/SNFist)•Home care innovation (mobile observation/telemonitoring) •Urgent care

Patient Engagement •Shared decision making•Customized decision aids and educational materials

Infrastructure •Single EHR platform with advanced decision support •Data warehouse, analytics, performance metrics

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And why these programs?

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Primary Care •Patient Centered Medical Home (PCMH) •High risk care management (palliative care) •Mental health integration •Virtual visits

Specialty Care •Active referral management (eConsults/curbsides)•Virtual visits• Procedural decision support (appropriateness)•Patient reported outcomes •Episodes of care (bundles)

Care Continuum •SNF care improvement (network/waiver/SNFist)•Home care innovation (mobile observation/telemonitoring) •Urgent care

Patient Engagement •Shared decision making•Customized decision aids and educational materials

Infrastructure •Single EHR platform with advanced decision support •Data warehouse, analytics, performance metrics

Develop team based care

Demonstrate value in procedures

Reduce post acute variation

Empower patients in their care

Information -> Insight -> Action

Promote Medical Neighborhood

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Successful ACOs will use predictive analytics to launch a high risk care management program

High risk patients - those at risk of being high cost

Not Chronically

Ill, Medically Complex

Medically Complex

Primary Care

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Chronic Condition

Mental Health Disorder

Patients with a mental health disorder have 40% higher chronic condition costs

Significant opportunity in integrating mental health services into primary care

Mental Health

Primary Care

Better identify patients Increased screening

Better triage of patients Phone access line with referral support

Better use of protocolsIMPACT for depression, SBIRT for substance abuse

Better self-management Online patient-directed therapy (iCBT)

Better access to services

Better tracking outcomes IT tools tracking longtitudinal progress, Patient reported outcomes measurement

Examples [Current and Future]Key Elements

Embedded mental health resources, consulting psychiatrist

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Primary Care

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Virtual visits allow us to connect to patients in more convenient ways (and avoids unnecessary office visits)

Asynchronous

Models that deliver care to people without requiring real-time interaction

Synchronous

Models that allow people and providers to connect in real time

Specialty Care

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Patient Reported Outcome Measures are outcomes that matter (and demonstrates value to market)

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Direct collection of information from patients regarding symptoms, functional status, and mental health.

Func

tiona

l Sta

tus

time

Surgery

Tier 1: Health status achieved

Tier 2: Process of Recovery

Tier 3: Sustainability of Recovery

Specialty Care

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We can improve a patient’s surgical journey(and avoid unnecessary or unwanted surgeries)

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Patient with a

Surgical

Problem

Assess Appropriateness

Criteria

Schedule OR

Procedure Recovery Physician Encounter

Possible Need for

Procedure

Shared Decision Making

Pre-Procedure

Testing

Short-term Outcome Measures

Long-termOutcome Measures

Personalized Risk

(Consent Form)

Informed Consent

PROs Survey(s)

PROMsPrOE (Procedure Decision Support)PROMs

Milford CE, Hutter MM, Lillemoe KD, Ferris TG. (2014). Optimizing appropriate use of procedures in an era of payment reform. Annals of Surgery 206(2): 202-204

Specialty Care

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Nationally, these 7 procedures account for $56.6 billion, or 55% of the total costs of the 20 most

costly procedures in the US:• Spine fusion• Spine laminectomy• Knee arthroplasty• Hip replacement• PCI• CABG• Heart valve repair

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We target the most costly procedures

Specialty Care

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Clinical

Office

MGH Admit-ting

Payer

Patient visits surgeon and lumbar laminectomy is indicated

Surgeon schedules procedure

Admin knows procedure requires PA?

Admin faxes form to admitting

Admitting checks for form

Admitting submits PA

PA reviewed by third party

Decision submitted to Admitting Manually

appeal claim

Admitting enters auth # in PATCOM

Patient undergoes procedure

Admitting checks for form

Admitting calls clinic to work through PA form

No

Yes

Denied

PrOE completed

PrOE PA form sent to Admitting

PA is granted without third party review

Authorization submitted to Admitting

Potential savings:• Current process: o 4-5% denial rate, o <1% ultimately denied

• PrOE process:o Produces same result (<1%

denial rate) o Reduces administrative

burden

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Ultimately, we have created a more efficient prior authorization

Specialty Care

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We can do a better job in helping our patients understand their healthcare encounters….

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Redundant, inconsistent, and perishable educationalencounters in healthcare

Problem

Reduced provider productivity and patient satisfaction

Outcome

Patient Eng.

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… by providing a non-perishable, personalized solution to patient education

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Redundant, inconsistent, and perishable educationalencounters in healthcare

ProblemImproved provider productivity and patient satisfaction

Outcome

Provider-generated, video-based educationprescribed to patients before, during, and afterclinical encounters.

Solution

Patient Eng.

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We believe personalized non-perishable education will improve outcomes and satisfaction

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• Series of short, single-topic videos featuring a patient's own healthcare provider.

• Improve provider efficiency, increase patient engagement, and improve clinical outcomes

Patient Eng.

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Thank you! Thoughts or questions?

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MGH NY Cardiac Database0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Rarely Appropriate

Maybe Appro-priate

Appropriate

Appropriateness Scores for Diagnostic Catheterization by Month (all AUC Indications)

Aug Sept Oct Nov Dec0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

*Hannan, EL, et al. Appropriateness of Diagnostic Catheterization for Suspected Coronary Artery Disease in New York State. CIRC INTERVENTIONS. January 28, 2014. 113.000741

n=156 n=8986

Median hospital-level inappropriateness rate is 28.5%*

Appropriateness Scores for Diagnostic Catheterization for Suspected CAD at MGH vs. NY

Cardiac Database*

Appropriateness Results: Diagnostic Cath

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Appropriateness Data Repository

Procedure Scheduling

PrOE Appropriateness tool

Public Reporting

PCI, CABG, Vascular,

Harris Joint

Internal Performance Dashboards

Billing and Prior Authorization

RPM, RPDR, CDR, EMPI

Pre-populated data fields (NLP search)

INPUTS OUTPUTS

Personalized consent formExisting

registries

LMR, OnCall

Data storage

EMR

Appropriateness Indications & Decision support

Measurement & analysis of appropriateness and outcomes

inform guidelines and indications in real-time

Data passback to registries (Web service)

Copy of appropriateness results placed in LMR and CDR

EHR note created

PrOE: Inputs and outputs

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Analytic Insights

AQuestions &

Answers

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Session Feedback Survey

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1. On a scale of 1-5, how satisfied were you overall with this session?1) Not at all satisfied2) Somewhat satisfied3) Moderately satisfied4) Very satisfied5) Extremely satisfied

3. On a scale of 1-5, what level of interest would you have for additional, continued learning on this topic (articles, webinars, collaboration, training)?

1) No interest2) Some interest3) Moderate interest4) Very interested5) Extremely interested

2. What feedback or suggestions do you have?

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Upcoming Keynote Sessions2:20 PM – 3:10 PM

23. Predictive and Suggestive AnalyticsDale SandersSenior Vice President, Health Catalyst

3:25 PM – 4:25 PM

24. From The Heart: Healthcare Transformation From India To The Cayman IslandsDale SandersSenior Vice President, Health CatalystChandy Abraham, MDChief Executive Officer, Director of Medical Services Health City, Cayman IslandsGene Thompson, Health City Director, Director of Thompson Development, Ltd.

4:15 PM – 4:45 PM

25. Closing KeynoteDan Burton, Chief Executive Officer, Health Catalyst

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Location

Main Ballroom