Population Health: Managing Across the Spectrum of Care Dana H. Smetherman, MD, MPH, FACR Vice Chair, Department of Radiology Ochsner Health System 1
Nothing to disclose 2
• Introduced by Institute for Healthcare Improvement in 2008 • Approach to optimizing health system performance 3
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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 or hospital. 5
Health Care Spending as % of GDP US NHE > $3 Trillion in 2016 6
CMS National Health Care Expenditure Trends & Projections • 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 • 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 9
The Fundamental Problem: Misaligned Payment Systems Fee For Service Population Health Model Model Reactive Proactive Payment For Each Service Provided Payment For Individual Incentivizes More Services Incentivizes Prevention
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Targeted Risk Stratification for Population Health Manage top 3% of the current population • Complex Care Management • COMPLEX Primary Care Lead Connected Care Team • CARE IP-OP continuity & collaboration • Advanced Care Services Manage 20% of the population CARE COORDINATION • Primary Care coordination • Specialists (e.g. ortho) • Registries • Care pathways • Ancillary support staff (behavioral health, etc.) DISEASE MANAGEMENT • Select disease-specific programs Manage rising PREVENTIVE HEALTH risk population
Uninsured Population in the U.S. Before & After ACA • 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
ACA Preventive Services • 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
Medicaid Expansion in Louisiana Insights for Population Health 17
Louisiana Ranked #49 in Overall Health Metric U.S. Rank 45 th Diabetes 47 th Cancer Deaths Cardiovascular Deaths 46 th Infant Mortality 48 th Premature Death 47 th Preventable 47 th Hospitalizations 45 th Physical Inactivity http://www.americashealthrankings.org/explore 18
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The Louisiana Experience Medicaid Expansion • 1/11/16: Gov. John Bel Edwards takes office • 1/12/16: Signs executive order to expand Medicaid in LA • 1/14/16: President Obama visits
Medicaid Expansion in Louisiana (Population 3 million) • 1 st 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 • 1 st 12 months: – 431,568 enrolled – 100,703 received preventive care
The Louisiana Experience Medicaid Expansion 3 months 6 months 12 months Colonoscopy 1246 4102 10,538 Colon CA 15 45 157 (7/1000) (12/1000) (11/1000) (15/1000) Mammography 1000 4583 15,193 Breast CA 24 58 154 (5/1000) (24/1000) (13/1000) (10/1000) 22
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)
CMS National Health Care Expenditure Trends • 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)
Population Health Ochsner’s Plan 25
Ochsner Health System & Ochsner Health Network • Louisiana’s largest non - • Multi-state (LA, MS) profit, academic, clinically-integrated healthcare system. network • 30 owned, managed, and • 4000+ aligned providers • Centralized support affiliated hospitals • More than 60 health infrastructure centers. – Case management • Over 1,000 employed – Analytics physicians & over 600 – Performance APP’s management 26
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On Demand Access • 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 30
Ochsner Post-Acute Care Solutions 31
Grow Primary Care 32
Ochsner Medicare: Population Health Scorecard MSSP Humana MA PHN Measure 12 mos Roll 12 mos Roll 12 mos Roll 12 mos Roll June 2016 % Change % Change Sept 2015 Sept 2016 Oct 2015 Oct 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 BIG7 Ambulatory Quality Metrics # needed to reach Metric Q2 2016 Q3 2016 Q4 2016 Q1 2017 QTD 2017 Target 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 34
Ochsner Epic Healthy Planet Registries 35
Health Risk Assessments
Leveraging Technology – Patient Portal
Digital Innovation Hypertension Management 38
Digital Innovation Hypertension Management • % Achieving Hypertension Control over 6 months • 880 patients enrolled • 79% with digital management • 24% with usual care New Concepts in Hypertension Management: A Population- BasedPerspectiveMilani, Richard V. et al. 39 Progress in Cardiovascular Diseases , Volume 59 , Issue 3 , 289 - 294
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 40
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