Outside the Walls: Examining New Opportunities to Successfully Achieve Population Health Improvement Communities Achieving Excellence and Accountability Conference Friday, January 25, 2019 Vondie M. Woodbury President The Woodbury Group
“Successful redesign of health care is a community by community task. That’s technically correct and it’s also morally correct, because in the end each local community – and only each local community – actually has the knowledge and the skills to define what is locally right.” --Don Berwick
Health Care Transformation – Drivers of Change • Delivery Restructuring • Integrated Delivery • PCMH – Team Based Approach • Patient Engagement • Individual Health Assessment • Prevention – Keeping People Well • Personal Participation • Data Driven • Risk Stratification • Measure for Quality/Clinical/Access and Cost Goals • Payment For Value Not Volume • Target (reduce) high frequency use • Improve Outcomes • Community Assets and Public Health Tools • Community Needs Assessment • Environmental and Socioeconomic Factors
Things To Consider This Morning and Going Forward.. Health Care is Undergoing Rapid Transformation Moving from Volume to Value Think: Auto Industry 1970’s and ‘80’s Redesign is at Multiple Levels Hard wired data and value - ROI Three-level Chess National – Policy Change and Payment States – Medicaid as a Laboratory Local – Place-based Disruption We Are All Now In the Business of Health Care What is Your Next Step?
Triple Aim, Value-Based Purchasing and Coverage Expansion Drive Change Triple Aim Move to Value-Based Purchasing The goals of improved health, improved care quality, and Increased Coverage lower per capita cost of care New public and private have become the organizing payment models are holding With Medicaid expansion for framework for the U.S. health providers accountable for adults with incomes up to care system, injecting patients’ health care quality and costs; 133% FPL and the availability social needs into the health almost two-thirds of providers of subsidized coverage for care continuum report they are signing value- individuals and families with based contracts with incomes up to 400% FPL, commercial payers 1 Slide used with permission of Deborah Bachrach Manatt, Phelps & Phillips, LLP Research Funded by: The Commonwealth Fund, the Pershing Square Foundation and the Skoll Foundation. 1 J. Stone, “Survey Results: Percentage of Providers Taking on Risk Doubled Since 2011” (New York: The Advisory Board Company, June 5, 2013), http://www.advisory.com/Research/Health-Care-Advisory-Board/Blogs/Toward-Accountable-Payment/2013/05/Accountable- payment-survey
Payment Drivers…the Business Case for Change Delivery models that incorporate interventions addressing patients’ social needs may be eligible for enhanced reimbursement, such as through: Payment incentives for Patient-Centered Medical Home (PCMH)-recognized providers, that are required to deploy care coordination and self-care supports with linkages to community social Enhanced service agencies Reimbursement Health home provisions under the Affordable Care Act (ACA), which allow for reimbursement for social interventions targeted towards complex, chronically ill patients New Medicare payment codes for complex care management services that assess and address patients’ psychosocial needs Shared savings programs incentives providers to reduce spending on a defined patient populations. by sharing savings. Providers who are successful in shared savings programs address their patients’ social Shared Savings needs. Examples can be found in: Medicare Shared Savings Program and Pioneer ACO Program Medicaid ACO pilots New capitated payment models require providers and provider systems to take risk for managing covered services within a fixed budget, implicating patients’ social needs. Examples include: Capitated, Global, and Medicare Bundled Payments for Care Improvement Initiative Bundled Payments Oregon Coordinated Care Organizations Medicaid managed care organizations, including emerging programs for dual eligibles Social factors are linked to readmissions risk. Providers are now financially penalized for excess 30-day readmissions under the ACA’s Medicare Hospital Readmission and Reduction Program, incentivizing Readmission Penalties hospitals to address social needs as part of their efforts to reduce readmissions .
Integrated Delivery Networks – Community Health How will large integrated systems connect with diffused community infrastructure?
The Patient Centered Medical Home – Direct Community Linkage • Team Based Care – Not Physician Centered – Patient Centered • Physician • Nurse • Medical Assistant • Care Coordinator • CHW • Social Worker • Access is Convenient • More online tools • Appointment and Personal Information • Focus is on Wellness & Prevention • Health Coach • Targets behaviors • How Patient Experiences Care is Critical • Patient Assessment for SDH • Satisfaction with Service – ties to reimbursement • Process Improvement is Continuous • Care is Coordinated • Embedded Care Management • Coordination Across Clinical and Community Settings • Data
Getting Outside the Walls…. • You cannot go it alone. • Success requires partnership with community. • It takes time to find common ground and build trust. • The challenge: bridge differences Population Health cannot succeed without linking directly to the places where people live, work and play.
Social Determinants - 2014 Modern Healthcare – February 3, 2014 The “X”Factor in Disease Management “Healthcare systems in impoverished areas are turning toward tackling the social conditions that lead to ill health, but they may pay a financial penalty since payers still do not reimburse for those activities.” “A recent study in Health Affairs found the risk for hospital admission for hypoglycemia in low- income patients with diabetes increased by 27% during the last week of the month when food budgets are strapped and food stamps run out – compared with the first week of the month. “
Resource Alignment: Addressing Those With Greatest Need Complex Patients & Multiple Social Determinants Identify and use community assets to stabilize people Homeless High risk pregnancy Parolees Behavioral Health Including Substance Use Multiple Chronic Conditions Dual Eligible – poor and fragile Heavy use of ED
Clarke’s Story Personal Situation Medical Situation History of Chronic Illness Homeless Entered through ED No Income/No Job Hospitalized – Including Intensive No Primary Care Physician Care Substance Use Disorder – long term Diagnosed with Ventricular Aneurism Uninsured Stabilize for Surgery No Family or Other Support System Discharged with Physician Orders Failed Mental Health Exam including daily monitoring of medication – Coumadin No Personal Identification/Paper Trail Bill at Discharge: $25,000 No Transportation No Ability to Manage Diet
“If the not -for-profit hospitals that dominate the healthcare system really want to become health stewards of the populations in their catchment areas —and not just “sick care” institutions — their community benefit priorities need to change.” Modern Healthcare - 2016
Before ACA: Hospital CB Programming/Investment – Chaotic Sponsored by Board Sponsored by Board Sponsored Activity by Physicians Activity Activity Sponsored Activity Disorganized Chaos Sponsored by Activity by Administration Physicians Activity Activity Sponsored By Activity Sponsored Mission By Community Benefit Sponsored by Nursing
The Needs Assessment and Implementation Plan – 501(r) CONDUCT ASSESSMENT – GATHER AND ANALYZE DATA • Shared Process • In collaboration with others • Hospitals, state, local health departments, community* • Demographic data – qualitative and quantitative INCLUDE INPUT FROM PERSONS • State, local, or regional governmental health department • Members medically underserved, low-income, minority populations • Written comments on previous assessment and implementation strategy *Joint assessment and implementation strategy permitted if same definition of community used by all participants and each hospital clearly identified .
Poor Accountability Drives New Requirements Hold non-profit hospitals to a higher standard; Penalize those that don’t deliver; Failure to complete CHNA or CHIP face a potential $50k fine; Penalties can accumulate and might jeopardize tax exemption;
Define and Validate Needs Assessment Priorities Establish criteria to identify priorities - could include 1. Burden 2. Scope 3. Severity or urgency of the need 4. Estimated feasibility and effectiveness of interventions 5. Health disparities associated with the need 6. Importance the community places on addressing the need Identify priorities with community input using methods such as ranking, discussion and debate; Validate priorities - confirm with community and internal staff
Community Benefit Requirements - Every 3 years – Every nonprofit hospital is audited for compliance; - There is a sense that hospitals are not doing enough; Transparency… - http://www.communitybenefitinsight.org - Mr. Grassley is returning to the Finance Committee – reportedly – is interested the progress by hospitals since the ACA passage;
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