Managing Across the Spectrum of Care Dana H. Smetherman, MD, MPH, - - PowerPoint PPT Presentation

Population Health: Managing Across the Spectrum of Care

Dana H. Smetherman, MD, MPH, FACR Vice Chair, Department of Radiology Ochsner Health System

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Nothing to disclose

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• Introduced by

Institute for Healthcare Improvement in 2008

• Approach to
• ptimizing health

system performance

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Population Health

• System of care that

aims to improve the health of a defined population for which we have financial responsibility.

• Health system is

responsible for total care of patients 24/7, not just when in clinic

• r hospital.

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Health Care Spending as % of GDP

US NHE > $3 Trillion in 2016

• Historically low growth

rate in health care spending 2002 – 2014

• Growth rates began to

rise in 2014

• From 2016 – 2025, NHE

projected to grow at avg. rate of:

– 5.6% per year – 4.7% per capita – 1.2% faster than GDP per year

CMS National Health Care Expenditure Trends & Projections

CMS National Health Care Expenditure Trends & Projections

• Healthcare’s share of

GDP expected to rise to 19.9% in 2025

• Projected to continue to

grow at a faster rate than GDP due to:

– Costs of coverage expansion under ACA – Prescription drug costs – Aging population

Transition to Value Based Reimbursement

• Government & Commercial Insurers transitioning

delivery & payment models away from FFS

• Affordable Care Act – insurance reform & coverage

expansion

• MACRA (QPP) – physician payment reform

– MIPS – Value based payment for FFS Medicare – APM’s

• CMS push to bundle CPT payments
• HHS Secretary Burwell’s 2015 goal for 50% of Medicare

payments to be in APM’s by 2018

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Fee For Service Model

Reactive Payment For Each Service Provided Incentivizes More Services

Population Health Model

Proactive Payment For Individual Incentivizes Prevention

The Fundamental Problem:

Misaligned Payment Systems

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COMPLEX CARE CARE COORDINATION DISEASE MANAGEMENT PREVENTIVE HEALTH

Manage top 3% of the current population

• Complex Care Management
• Primary Care Lead Connected Care Team
• IP-OP continuity & collaboration
• Advanced Care Services

Manage 20% of the population

• Primary Care coordination
• Specialists (e.g. ortho)
• Registries
• Care pathways
• Ancillary support staff (behavioral health, etc.)
• Select disease-specific programs

Manage rising risk population

Targeted Risk Stratification for Population Health

• According to the

CDC:

– No significant change from 2004 - 2013 – % of persons under age 65 who were uninsured decreased 37% from 2013 to June 2015

10.5% under the age of 65 were uninsured 12.7% 18-64 uninsured

Uninsured Population in the U.S. Before & After ACA

• ACA’s aim (per CMS website) – to expand access &

lower cost barriers to health care

• Health plans must provide coverage for preventive

services without cost-sharing

• Required preventive services recommended by 4

expert medical & scientific bodies:

– USPSTF – Advisory Committee on Immunization Practices (ACIP) – Health Resources & Services Administration’s (HRSA’s) Bright Futures Project – HRSA & IOM committee on women’s clinic preventive services

ACA Preventive Services

• Per CMS Website, HHS Assistant Secretary

for Planning & Evaluation estimates:

– 137 million people have received no-cost coverage for preventive services since ACA

55.6 million women 53.5 million men 28.5 million children

– BUT only 43% of population aware that ACA eliminated out of pocket expenses for preventive services

ACA Preventive Services

• Cooper et al, Cancer 2016 :

– Medicaid expansion states had increased compliance with screening mammography across every socio-economic status (including poorest)

• RSNA 2015 Abstract

(Dehkordy et al.)

– Self-reported screening mammography compliance decreased b/w 2008 & 2012 in states with & without expansion – BUT adjusting for age, race, education, and income: low- income women in expansion states were 25% more likely to adhere to screening in 2012 compared to 2008

Cooper, G. S., Kou, T. D., Dor, A., Koroukian, S. M. and Schluchter, M. D. (2017), Cancer preventive services, socioeconomic status, and the Affordable Care Act. Cancer. doi:10.1002/cncr.30476

ACA Preventive Services

Medicaid Expansion in Louisiana

Insights for Population Health

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Metric U.S. Rank Diabetes 45th Cancer Deaths 47th Cardiovascular Deaths 46th Infant Mortality 48th Premature Death 47th Preventable Hospitalizations 47th Physical Inactivity 45th

http://www.americashealthrankings.org/explore

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Louisiana Ranked #49 in Overall Health

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• 1/11/16: Gov. John

Bel Edwards takes

• ffice
• 1/12/16: Signs

executive order to expand Medicaid in LA

• 1/14/16: President

Obama visits

The Louisiana Experience Medicaid Expansion

Medicaid Expansion in Louisiana (Population 3 million)

• 1st 6 months:

– 378,564 enrolled – 50,622 received preventive care – 2,276 patients were newly diagnosed with hypertension – More 11,500 new members received a flu shot

• 1st 12 months:

– 431,568 enrolled – 100,703 received preventive care

3 months 6 months 12 months

Colonoscopy 1246 4102 10,538 Colon CA (7/1000) 15 (12/1000) 45 (11/1000) 157 (15/1000) Mammography 1000 4583 15,193 Breast CA (5/1000) 24 (24/1000) 58 (13/1000) 154 (10/1000)

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The Louisiana Experience Medicaid Expansion

• Prevalence screen for every disease (colon cancer, breast

cancer, hypertension,…)

– Screening introduced into new population – Previously undetected disease that has been building up in the population detected – Results in apparent rise in # cases

• Once prevalence cancers (& other diseases) identified:

– Incidence will return to pre-screening level – New cases will be detected at an earlier stage

• BOTTOM LINE: Costs associated with newly covered

population high initially until population passes through the prevalence screen (higher # + later stage disease in prevalence screen)

The Louisiana Experience Medicaid Expansion

• Projected to continue

to grow at a faster rate than GDP due to:

– Costs of coverage expansion under ACA (may level off) – Prescription drug costs (currently unregulated, not part of MPFS) – Aging population (will continue)

CMS National Health Care Expenditure Trends

Population Health Ochsner’s Plan

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• Louisiana’s largest non-

profit, academic, healthcare system.

• 30 owned, managed, and

affiliated hospitals

• More than 60 health

centers.

• Over 1,000 employed

physicians & over 600 APP’s

• Multi-state (LA, MS)

clinically-integrated network

• 4000+ aligned providers
• Centralized support

infrastructure

– Case management – Analytics – Performance management

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Ochsner Health System & Ochsner Health Network

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• Acquired 12 Urgent Care

& 4 Occupational Medicine Clinics

• Epic installation in

Summer 2017

• Transition to all employed

physicians

• “Do You Feel You Need to

be Seen Today?”

• After hours expansion

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On Demand Access

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Ochsner Post-Acute Care Solutions

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Grow Primary Care

Ochsner Medicare: Population Health Scorecard

Measure MSSP Humana MA PHN 12 mos Roll Sept 2015 12 mos Roll Sept 2016 % Change 12 mos Roll Oct 2015 12 mos Roll Oct 2016 % Change June 2016 YTD

Total Cost of Care PMPM Total Medical PMPM Total Pharmacy PMPM UTILIZATION Admits/1000 ED visits/1000 (incl. obs) Readmits/1000 Readmit % Imaging Radiology/1000 MRI/1000 CT/1000 Outside Provider Expense QUALITY Quality Rating HbA1c < 8.0 BP Control <140/90 Mammography

“BIG 7” Ambulatory Quality Metrics

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BIG7 Ambulatory Quality Metrics

Metric Q2 2016 Q3 2016 Q4 2016 Q1 2017 QTD 2017 Target # needed to reach target Numerator Met Measure Denominator

Breast Cancer Screening 68% 68% 68% 68% 68% 80% 8,351 43,869 65,275 Cervical Ca Screening 45% 50% 51% 50% 50% 70% 23,978 60,834 121,160 Colorectal Ca Screening 58% 59% 59% 59% 59% 71% 16,519 83,969 141,532 6 or more Well child visits 47% 49% 77% 80% 122 2,390 3,140 Diabetes Control (A1c<8) 71% 71% 69% 69% 81% 4,089 22,243 32,509 Blood pressure Control (<140/90) 58% 58% 58% 60% 60% 75% 19,607 74,863 125,960 DM Eye exam 46% 48% 50% 51% 51% 75% 8,030 16,312 32,456

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Ochsner Epic Healthy Planet Registries

Health Risk Assessments

Leveraging Technology – Patient Portal

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Digital Innovation Hypertension Management

• % Achieving Hypertension Control over 6 months
• 880 patients enrolled
• 79% with digital management
• 24% with usual care

39 New Concepts in Hypertension Management: A Population- BasedPerspectiveMilani, Richard V. et al. Progress in Cardiovascular Diseases , Volume 59 , Issue 3 , 289 - 294

Digital Innovation Hypertension Management

Leveraging Technology Pre-Natal Care

Connected Mom:

• Education & resources through

health coach

• Periodic educational texts
• Congratulatory texts from OB

at pregnancy milestones

• List of available pediatricians
• Additional reminders for

vaccines and screening

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• The quadruple aim provides a framework for

improvement of the US health care system.

• Population health, if accomplished on a large scale,

could be a long term strategy to both improve outcomes and control health care costs.

• Lessons learned from the Medicaid expansion in

Louisiana confirm that initial costs of population health will likely be high until prevalence screen is complete.

• Health care systems must develop integrated strategies

to address population health throughout the spectrum of care.

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Conclusion