Navigating the Future of Healthcare A New Model of Care Delivery

Navigating the Future of Healthcare: A New Model of Care Delivery Leslie Schwab, MD Kenneth H. Paulus November, 2007 Agenda • Review Allina and Harvard Vanguard Structure • Discuss market and key drivers for change • Review the Allina and Harvard Vanguard strategy and patient care model • Key Imperatives What is Allina Health System? • 501c3 non-profit organization • $2.5B health care delivery organization covering the state of Minnesota and western Wisconsin • 23,000 employees • Two tertiary hospitals, three community hospitals, six rural hospitals, a 500 physician clinic with 40 sites What is Harvard Vanguard? • 501c3 non-profit group practice • $1.0B health care delivery organization covering the state of Massachusetts • 6,000 employees • 600 physicians and 250 NP/Pas • 350,000 patients • Even mix of primary care and secondary specialty care What is wrong with health care in the States and what is being done about it? • Costs are „out of control‟ • Quality is not optimal, with no real breakthrough in sight • Value is significantly behind that of other developed countries • There is an opportunity for a significant breakthrough, and it is likely to happen in the next 10 years Costs continue to rise at a steady pace… How are costs changing by diagnosis? Cardiac, Orthopedics, Cancer are the Largest Cost Drivers em e st ss u Sy Ti v y o r nc t m at te ul , C irc u lo s S ys - C k sm ry s us 07 M pl a ri na ion i ng - eo u t rp di on o 13 ue - N enit Con ois P em th,P ans 02 G er r st nd rg th bi 10 O ry a S y il d e O h u ve ns un ,C 17 Inj sti m cy , Se m e ig s an ,Im te 16 - D egn Sy ys oli c 09 Pr ou s ry S tab ue e rv to ss 11 Ne ira ri,M Ti p ut d s es es rio ou ,N 06 Pe ane Cod - R dcr t al 08 En is at bc u /E D in es tic er Su 03 si od & -P C ra s s n ki ie 15 al Pa an al rg du & -S m O si us 12 Re no m tio l A For ec ta 18 d ni nf -I oo ge rs Bl on 01 & de - C od or is 14 lo lD -B ta 04 en n w -M no nk 05 99 -U $30.00 $25.00 $20.00 $15.00 $10.00 $5.00 $0.00 20 03 20 Q4 04 Q 20 1 04 Q 20 2 04 Q 20 3 04 Q 20 4 05 Q 20 1 05 Q 2 20 05 Q 3 How is the industry responding to this challenge? 1. Pass on financial risk and responsibility to the consumer/patient 2. Hold providers accountable for quality and costs via „pay for performance‟ reimbursement Employers are shifting costs to employees $3,552 Dramatic increase in out-of-pocket costs for insured employees $861 $2,276 +56% Co-pay, deductible $580 $2,691 Contribution to premium $1,696 (wage growth = 12.3%) 2000 2004 Early results of cost shifting to patients… • Significant reduction of Behavioral Health visits – 30% • Sizeable reduction of physician office visits – 15% • Slight reduction of ED visits – 5% • Virtually no impact on hospital utilization Pay for Performance: Does physician practice variation contribute to outcomes? Distribution of Interventional Cardiologists: Cleveland 120 115 110 Quality Score 105 100 95 1 1 1 3 1 90 85 80 0.8 0.6 0.4 0.2 0 -0.2 -0.4 -0.6 -0.8 Efficiency (Cost Compared to Market Average) Bubble size reflects number of cases seen by MD What are the key factors that drive good hospital performance? Continuous Quality Improvement Emergency Cardiac Care 120 Min Street to PCI Operator Experience Inv. Card:125/yr Surg:125/yr EP:50/yr Performance Measurement (STS , ACC, & JCAHO) Experience- Minimums PCI=400/yr Open Heart:450/yr Full Service (Surgical, Interventional Cardiology, EP) UHC Cardiac Services Trend $24.00 $22.00 How much does performance vary? UHC Cardiac Services Center of Excellence Trend Value $24.00 Non-COE Trend COE Trend UHC Blended Trend Cardiac Services PMPM $20.00 $18.00 $16.00 $14.00 $22.00 $12.00 $20.00 Apr-04 Au Cardiac Services PMPM g0 O 3 ct -0 De 3 c0 Fe 3 b0 Ap 4 r- 0 Ju 4 n0 Au 4 g0 O 4 ct -0 De 4 c0 Fe 4 b0 Ap 5 r- 0 Ju 5 nAu 0 5 g0 O 5 ct -0 De 5 c05 18% Trend $18.00 $16.00 $14.00 3-4% Trend $12.00 Aug-03 Aug-04 Apr-05 Aug-05 Oct-03 Oct-04 Dec-03 Dec-04 Oct-05 Source: UHC Dec-05 Jun-04 Feb-04 Feb-05 Jun-05 Other complicating factors… Estimated Physician Supply and Demand, 2020 1,100,000 # of physicians 1,050,000 1,000,000 950,000 900,000 850,000 972,000 1,060,000 800,000 750,000 Number of Physicians Projected 2020 Number of Physicians Needed by 2020 A 15% increase in U.S. medical graduates by 2015 is required to offset the shortfall. Other complicating factors… National Supply and Demand Projections for FTE RNs 2000 - 2020 RN FTE Demand Shortage of over 2,300 2,100 1,900 1,700 2,900 2,700 2,500 FTEs (Thousands) 1,000,000 nurses in 2020 RN FTE Supply 1,500 2000 2005 2010 2015 2020 First, attack the problem from a population perspective… Cost Acuity Second, break down the problem/opportunity into manageable components… The Well The Chronically Ill The Acute End of Life 1st Imperative: Prevent illness efficiently • There is not enough money in the system to manage wellness using physician or nurse time Information technology has the potential to drive significant improvements in health very inexpensively – – On-line risk assessment with automated link to provider team Regular „alerts‟ to patients to drive health improvement • The Well • The assessment of health and genetic risk will start with the patient, and the transfer of knowledge will provide the tools for improvement 2nd Imperative: Aggressively manage chronic illness through the primary care team • The management of chronic illness should be the domain of the primary care team Provide these teams the information needed to assess their panel of chronic illness patients and measure performance Re-define the roles of the team to push simple chronic illness care and education to the nurse/NP Develop centralized and virtual disease management programs that improve outcomes efficiently The Chronically Ill • • • 3rd Imperative: Concentrate acute and tertiary care at Centers of Excellence • Drive tertiary care centrally to reap the benefits of volume and expertise • Establish clear performance metrics for outcomes and cost • Link acute care Emergency and ICU with community providers effectively – Level I program – eICU The Acute 4th Imperative: Provide effective critical and palliative care • A significant percentage of costs reside in care provided in the last six months of life • An effective palliative care program reduces costs and improves perceived quality • The use of data to track the critically ill provides an opportunity for significant savings • A program of targeted home and hospice care can be centralized effectively End of Life 5th Imperative: Integrate care across disease states – Cardiology, Cancer, Neurosciences, Rehab… • Profile provider and team performance by episode and disease treatment effectiveness • Integrate disease management activities across the entire care system – CHF program • Drive to high levels of evidence based care by specialty using EMR and data warehouse • Use nurse call center as integrator Patient Care Integration Case Study HVMA INTERNAL MEDICINE - 2007 • 170 MDs, 55 NPs & PAs, 50 RNs • 16 sites • 225,000 adult patients HVMA INTERNAL MEDICINE - 2002 • • • • • 35th % ile of patient satisfaction 50% of appts w/ PCP unstandardized team member roles limited disease management approach variable access for acute, chronic & preventive services THE BODENHEIMER CONUNDRUM (after Tom Bodenheimer, MD, UCSF) • Bad news: for a typical MD with 2500 patients, practicing the standard of care mandates 10 hours a day of chronic illness care and 8 hours a day of preventive care • Good news: there are still 6 hours available for acute care PATIENT CENTERED CARE MODEL 2002-6 • standardized roles and responsibilities • template management for access • reporting pt satisfaction data; communications training • population management Approach to Innovation: Population Segmentation Strategy 50 – 60 % 40 – 50 % Foundations of Care Resource Requirements Well / Preventive Care Chronic Illness Population Management Complex Chronic Care Intensive Home Based Care Approach to Innovation Clinical Design Work • Green Team: Smoking Cessation Weight Management Health Risk Assessment Chronic Disease in Primary Care Complex Chronic Care Program Intensive Home Based Care Program • • • Yellow Team: Red Team: Blue Team: Intensive Home Based Care • Objective of Program: To improve the safety of inpatient to outpatient transitions for vulnerable elderly patients through focused, post-discharge home based care Goals for 2006: Reduce 60d re-hospitalization rates for high risk elderly patients with 2 admissions within 12 months • Intensive Home Based Care Home Based Intervention Geriatrics Expertise Home visits within 72h of discharge to clarify and adjust care management plans Complex interplay of multiple medical morbidities + unique psychosocial elements Coordination of Coordination of PCP, Hospitalist, Case Management, VNA, ECF Care Works with CCC program INTENSIVE HOME BASED CARE – RESULTS • 400 patients enrolled • $820 hospitalization expense saved/pt Complex Chronic Care Clinical Expertise Highly Trained Nurse Practitioners Outreach Capability Integrated RN Call Center Works with IHB Program Coordination of Bridge Primary Care, Care for Sick Pts Specialties, Hospitals, and Case Management Data Driven Improvement Regular Review of Clinical & Utilization Improvement Complex Chronic Care • Objective of Program: 2000 patients per year with multi co-morbidities Clinical Goals for 2006: – – Diabetes Care (A1c, LDL, SBP) Congestive Heart Failure Care • ACE/ARB Use? – Quality of Life (SF12v2) • • Utilization Goals for 2006: – CHF Rehospitalization Rates? HgA1c Control Median HgA1c 7.8 7.6 7.4 7.2 7 6.8 6.6 6.4 6.2 7.6 7.2 7 6.7 6.8 7.15 6.9 7.1 2003 2004 2005 HgA1c Control CCC Only CHF Only CHF - CCC Program Process Outcomes % DM/HTN/Lipid Pts with Rx for Statin 100% 90% 80% 70% 60% 50% 40% Control CCC Only CHF Only CHF-CCC Program % Pts with Rx 2003 2004 2005 CHRONIC DISEASE MANAGEMENT (CDM in PRIMARY CARE) Planned, proactive visits Patient selfmanagement Data –driven management “CDM” visit type, planned agenda, clinical guidelines Motivational interviewing and goal negotiation Population “dashboard” of screening, process, outcome and management measures Translation of Concepts into Practice Diabetes Dashboards • Translating Concepts into Practice Measuring Results Urgent MD MD + Only Only APC 13% 62% 69% 23% 35% 10% -20% 85% 99% 58% +2% 85% 100% 64% +5% MD + CDM 86% 94% 100% 83% +16% A1c x 2 LDL BP Composite Change from 12 months ago Translating Concepts into Practice Measuring Results Urgent Only % Pts with A1c > 9.0 Mean Change in A1c MD Only 18% -0.44 19% -5.58 7% -19.8 MD + APC 15% -0.39 20% -6.03 6% -22.7 MD + CDM 20% -1.13 10% -18.9 6% -24.9 75% -0.02 78% 0 67% -0.58 % Pts with LDL > 160 Mean Change in LDL % Pts with SBP > 160 Mean Change in SBP For Changes in HgA1c •Difference between MD Only &MD + CDM: p < 0.01 •Difference between MD Only & MD + APC: p =0.157 •Difference between MD Only & Urgent Only: p <0.01 OVERALL RESULTS PATIENT CENTERED CARE MODEL • patient satisfaction at 65th %ile of market • successful pay-for-performance results in disease management • standardized roles, responsibilities, workflows • 70% of visits with PCP • variably improved access WHAT DIDN‟T WORK • Clinician work not made easier • “top down” approach led to limited engagement • MD job satisfaction not improved • MD turnover and recruitment problematic • REM: Bodenheimer Conundrum: we still do not have 24-hour capacity for each panel‟s daily needs WHAT MIGHT WORK • all-staff engagement (e.g., “Lean” management) • disciplined focus on practice efficiency/job doability • continued shift to prevention • enlarged team: nutrition, social work, behavioral medicine • promotion of patient self management (intra and intervisit) • engagement of caregiving community THE ADVANCED MEDICAL HOME • a declaration of principles of progressive medical practice and financing recommendations • joint support from organizations of 330,000 PCPs: o American College of Physicians o American College of pediatrics o American Academy of Family Medicine • demonstration projects funded in Medicare 2007 7th Imperative – Leadership! Unrealized Performance Inadequate Resources Poorly Communicated Strategy Actions Required to Execute Not Clear Unclear Accountabilities Organizational Silos Realized Performance Unrealized Performance Inadequate Performance Monitoring Inadequate Consequences for Failure or Success Poor Senior Leadership Uncommitted Leadership Unapproved Strategy What will the model look like in the community? The Community Integrated with knowledge, information, and disease management with care provided appropriately, telephonically, electronically and virtually Primary Care Primary Care Primary Care Regional Specialties Community Hospital Regional Specialties/ Community Hospital Primary Care Primary Care Tertiary Center Regional Specialties/ Community Hospital Primary Care Final Thought… “If you think you can run an organization in the next 10 years the way you ran it in the last 10 years you are out of your mind” CEO Coca Cola