Population Health Update 2.1.2019 Board of Trustee Retreat 1 2 - - PowerPoint PPT Presentation

Population Health Update 2.1.2019 Board of Trustee Retreat

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Topics

AHS Population Health Activities Epic and Population Health Population Health Horizon

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AHS Population Health Activities

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Population Health SBU Activities

Transition to Risk-Based Reimburse- ment Partner to Enhance Access and Capacity Adopt Risk Stratification and Business Intelligence Tools Help Address Social Determinants

• f Health

Caring Healing Teaching Serving All Our M Mission ssion

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Population health is a AHS-wide strategy involving the entire continuum of care

Key Questions

What has AHS achieved to date in its journey toward population health? Has it been successful in those efforts? What opportunities still exists?

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Context

Reimbursement is a significant driver in health care delivery system decisions and transformation

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Value-Based Payment (VBP)

 Health care payors hold health care delivery systems accountable for both quality and cost of care  Primary VBP mechanism is contracting - aim is to enhance population health management that improve health and/or systemic cost containment  Uses alternative payment models or pay-for-performance arrangements to create incentives and disincentives by tying compensation to certain performance measures intended to encourage better health care decision- making  Focused on both:

 Effective Healthcare - right patient, treatment, time, professional = right outcome  Efficient Healthcare - clinical & administrative work flows

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Alternative Payment Model

Alameda Health System (AHS) Medi-Cal Managed Care fee-for-service provider with both health plans since 1997 2020 Medi-Cal Waiver - PRIME Alternative Payment Model (APM) requirement

Penalties associated with not meeting requirements (reduction in PRIME funding)

As of January 2019, 60,500 managed care lives – 80% Alameda Alliance for Health and 20% with Anthem Blue Cross

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AHS Movement to Financial Risk (Compliance with State APM Requirement)

Planning Initiated (9.2017) Newark – Alliance Members – 9K (4.1.2018) Eastmont – Alliance Members – 12K (8.1.2018) Hayward – Alliance Members 13K (12.1.2018) Highland – Alliance Members 14K (3.1.2019) All Wellness Centers – Anthem Members (TBD) 10

APM Component How AHS Meets Requirement Defined Population Alameda Alliance managed care members assigned to AHS medical home Quality Component Alameda Alliance Quality Improvement P4P Program Financial Risk Primary care capitation

Phased Implementation (Primary Care Capitation)

APM Performance Metrics

 For State APM, Alameda Alliance requires AHS to meet additional performance metrics related to primary care access at Wellness Centers:

 Initial Health Assessment  Primary Care Visits  In-Network Specialty Utilization  Third Next Available Appointment: Return Visits  Emergency Department Visits per 1,000

 Updated baseline and improvement targets provided to AHS for each Wellness Center in January 2019  If AHS meets, add’l 5% payout to AHS; if AHS doesn’t meet, 5% claw back (risk-based arrangement)  AHS has developed a tracking tool; Ambulatory Care staff have access to

• utreach lists based on patient primary care utilization

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 Welcome to our system! …and come in for Initial Health Assessments (new Medi-Cal managed care patients)  Outreach to patients due for appointments via new registries and dashboards  Call center activity in follow-up to mailed letters

IHA Outreach Activities

IHA Outreach Results

Letters Call Center Activity Results from Completed Calls Letters Mailed (IHA due in Dec 2018 & Jan 2019) Calls to Make Calls Incomplete

• r Pending

Calls Completed Unable to Reach/Pt. Declined/ Transferred Care/Inactive 1st & 2nd Call Attempts /Left Msg Appts Scheduled All Results 1,028 1,028 234 794 286 468 40 794 100% 23% 77% 36% 59% 5% 100%

 Outreach efforts to new managed care members hampered by contact information (telephone and address) that may not be accurate and current  Restrictive federal laws on texting – individuals must opt-in as opposed to opting-out  E-mail addresses are readily available – exploring possibilities post-Epic

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AHS Accomplishments - APM

What’s Worked

 Met State requirement for APM  Infrastructure improvements  Fulfilled internal timeline for transitioning Wellness Centers to capitation – working collaboratively with Alameda Alliance  No negative financial impact – AHS continues to get Federally Qualified Health Centers rate for capitated Wellness Centers

What’s Continued Watch

 Outreach activities – will assess if

• ther strategies should be

approached  County-wide, collaborative approach to Medi-Cal managed care outreach  Tracking performance on primary access metric

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Key Questions

Given that AHS has fulfilled State APM requirement under 2020 Medi-Cal Waiver, should AHS receive VBP/risk-based payments for other services? What is the ideal ratio between fee-for- service and value-based reimbursement?

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Specialty Care Capitation

 Population health strategy to better coordinate care, address out-of-network utilization and reduce fragmentation  Capitating specialty care is more complex than capitating primary care  Factors under consideration

 Range of AHS specialty services versus Medi-Cal covered benefits  Division of Financial Responsibility  Financial analysis and capitation rate development  Provider contracting needed for services AHS does not provide  Infrastructure – claims adjudication, medical management (utilization, quality, etc.)

 Management service organization (‘build’ vs ‘buy’ decision) part of feasibility analysis  Timing

 Work on feasibility analysis begins in Spring 2019  Any specialty care capitation, if determined feasible, would have post-Sept. 2019 Epic go-live

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Global Capitation

 Capitation for all services (primary, specialty and inpatient) with exception of carve-outs and services managed by health plan (e.g., pharmacy)  Capitation would mean that AHS would be responsible for paying for emergency and inpatient services received by managed care members at non-AHS facilities  Recommended decision not to pursue due to:

 Significant out-of-network costs  State Department of Managed Health Care proposal that entities assuming "global risk" obtain licensure as a health care service plan  Infrastructure needs

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Factors Impacting Health

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Genetics & Biology, 10% Environment, 10% Clinical Care, 10% Health Behaviors, 30% Social & Economic Factors, 40% A determinant is an underlying factors that ultimately bring about disease.

Population Health Challenge

80% - 90% of the issues surrounding health are not within the control of the health care delivery system — socio-economic conditions and the choices patients have based on the environment they live in every day are key factors

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Meeting Social Needs differs from Addressing Social Determinants

 Addressing social determinants of health is important to achieving greater health equity (everyone has a fair and just opportunity to be healthier)  Conditions in which people are born, grow, live, work and age drive social determinants  Health care programs that offer food, transportation, temporary housing, etc. are valuable and are less costly than continually providing health care services to high utilizers  These strategies mitigate the acute social and economic challenges of individual patients  Important to recognize and support community-level policy actions for systemic change

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Addressing Housing Needs Medically Complex Patients

 Incidence of homelessness

 Rate of self-reported homelessness – an estimated 6% (7,100) of AHS patients (excl. community hospital data)  Of those 1,750 (25%) are homeless patients aged 60 and over (excluding community hospital data)

 Rationale for AHS intervention

 Homeless people’s health status will never improve while they remain homeless  Homeless people are extraordinarily expensive for health systems - the cost of providing/ facilitating housing is less expensive than the cost of doing nothing  Housing programs help health systems improve health outcomes for their communities  Health equity - Homeless and housing as a health care/public health issue

 AHS current activities

 Contracts with independent living facilities, licensed board and care facilities, a motel and a respite provider  Retained consultant to help explore options related to creating access to community-based housing opportunities

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AHS-County HCSA Partnership on Expanding Housing Options

 Alameda County HCSA set aside $1 million to house patients that were users of both County and AHS services  Last fall, Alameda County HCSA staff began participating in weekly long- stay committee meetings at Fairmont and Highland Hospital (Care Management) to identify housing for long-stay patients that are medically stable, but who have not been discharged - barrier to discharge is appropriate post-acute care placement/housing  Since forming this partnership, Alameda County HCSA has located housing for seven (7) long stay patients who have been discharged from Fairmont (4), Highland (2) and Park Bridge (1)  AHS maintains a waiting list which is reviewed regularly by Alameda County HCSA - currently 20 patients on the list

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Other Collaborative Efforts with AHS & Alameda Cty. HCSA Participation

 Medical Respite Care - acute and post-acute medical care for homeless persons who are too ill or frail to recover from a physical illness or injury on the streets, but are not ill enough to be in a hospital; short-term residential care  Whole Person Care – services and housing for Medi-Cal recipients who use services in multiple systems (e.g., health, mental health, criminal justice, etc.)

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Additional AHS Efforts

 Calif. Senate Bill 1152 (effective 1.2019) – Discharge planning and services for homeless patients  Other Activities

 Collection of data in our clinical systems  Collection of social determinants of health information and Epic build  Potential social services data from Alameda County Community Health Record/Social Health Information Exchange

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Key Question

As an anchor institution, how can AHS influence support community-level policy actions that will address social determinants of health?

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Epic and Population Health

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Key Question

How can Epic further population health efforts?

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Epic Software

Patient Experience Clinicals Specialties Mobile Care at a Distance Revenue Cycle Managed Care Population Health Community Connect Interoperability Gov’t Regulations

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Epic Promotes Population Health

 Healthy Planet  Care Management  Patient outreach  Tapestry – managed care module  Care Everywhere  Social Determinants of Health  Risk stratification/predictive modeling

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Structural Building Blocks

Value-based purchasing requires Population Health Management which requires Risk stratification

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Risk Stratification

 Population health management requires providers to develop the capacity to utilize data to risk stratify patients into groups and then respond to the needs efficiently and effectively  Risk stratification identifies and predicts which patients are at high-risk or potentially at high risk to better manage, prioritize and coordinate care to improve health outcomes and reduce costs  Can help prioritize clinical workflow, reduce system waste, and create financially efficient population health management programs  Based on the predictive risk score ranking, clinical staff are prompted to focus on those patients at highest risk and preemptively intervene with medication reconciliation, home visits, or follow-up appointments  Essential access to data and ability to parse it for clinical and operational decision making

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Using Utilization Data for Risk Stratification

 Receive Alameda Alliance member cost analysis for anyone with

• ver $5K in health care costs – 12 months of longitudinal data

 18% of Alameda Alliance top members are currently assigned to AHS  7.3% of Alliance members assigned to AHS consume 80.6% of total health care costs for all Alliance members assigned to AHS  171 members assigned to AHS had costs in excess of $100K over a 12 month period = total costs were ≈$32.5M (over half was for inpatient)

 In interim, will soon start providing data on these patients to Ambulatory Care and Care Management in an accessible format for clinical care planning (using Power Business Intelligence)  Long-term, will migrate to using Epic after go-live

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Population Health Horizon

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Trends

 Enhanced value-based purchasing – necessitates broader payer- provider collaboration  Increased focus and partnership on social determinants of health and corresponding patient behaviors – data and policy development  Expanded access to telehealth and non-face-to-face visits  Access and use of access to analytics for efficient and effective health care  Prioritization of population health under constraints — what do we want to happen every time and for which patients (e.g., SB 1152)

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APPENDIX

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Drivers of Population Health (Why)

Spending Variations in Care Outcomes /Quality

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Triple Aim: Better care for individuals, better health for populations and lower costs

Defining Population Health (What)

 Broad health care concept with multiple meanings  Population health is the health outcomes of a defined group of people, as well as the distribution of health

• utcomes within the group*

 This means that health equity – avoidable differences in health between different segments of the population – is a core part of understanding population health  Taking accountability for the outcomes of a population

39 * David Kindig, MD, PhD, and Greg Stoddart, PhD, Models for Population Health, AJPH 2003

Population Health Management (How)

KNOW The Population

• Identify patient

population, know what’s happening to utilization and predict what might happen

• Electronic Health

Record that can assist with longitudinal reporting, business intelligence/ analytics, and quality & regulatory reporting ENGAGE The Members

• Outreach to patients

and involve providers to improve health (engagement)

• Community-based

Care MANAGE The Outcomes

• Actively monitor cost,

quality and health

• utcomes/status of

patient population

• Manage capacity,

clinical programs and network

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Population Health Strategic Business Unit (SBU)

Improve clinical

• utcomes, patient

experience, and cost of care for defined populations by redesigning delivery, coordination and payment for healthcare services across the System of Care.

CORE FUNCTION CRITICAL SUCCESS FACTORS FACTORS

• Address access and capacity issue at Ambulatory to provide care

for assigned lives.

• Reach financial goals required by industry standards to allow

AHS to engage in capitation.

• Carve out adequate resources for implementing a change

management plan for care delivery. 41

Payment Reform

From Volume to Value – Payors, Patients & Providers want Quality

Fee for Service

• More services
• Less coordination
• Incentive for duplication
• Few incentives for prevention
• No to minimal link to quality

Value-Based Purchasing

• Removes incentives for

more services

• Rewards better outcomes
• Payments based on value –

quality

• Data driven
• Rewards patient satisfaction

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AHS Experience with Value-Based Payments

AHS receives incentive-based payments

Funding for meeting certain health care performance measures (e.g., HEDIS metrics)

Current initiatives

Medi-Cal Managed Care - Pay for Performance quality initiatives with both health plans PRIME (under the 2020 Medi-Cal Waiver) Quality Incentive Program (federal Medicaid Managed Care rule) Whole Person Care (aka Alameda County Care Connect)

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Capitation Promotes One Usual Source of Primary Care

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Assigned AHS Wellness Ctr. (WC) Any Other AHS WC Any Other Willing Alameda Alliance Primary Care Provider

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C a p i t a t i

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Any Other AHS WC Assigned AHS WC

Episodic

Coordinated

Activities Supporting APM

 Infrastructure activities

 Delegated functions  Major operational changes

 Patient experience  Continued focus on volume (i.e., face to face visits) and encounter submission

 Capitation does not mean providing fewer services  Visits/encounter volume have critical role in AHS funding

 Monitoring primary care access performance  Outreach activities

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Summary Patient Demographics

0-17 11% 25-44 39% 45-64 34% 65-74 9% 75+ 7% Age Group 0-17 25-44 45-64 65-74 75+ African American/ Black 25% Asian Pacific Island 14% Hispanic/ Latino 36% Caucasian/ White 17% Others 8%

Race & Ethnicity

Model & Patient Needs

Ongoing support Needs Assessment (Service Delivery/ Warm Hand-off) Patient is referred to the Health Advocates Patient presents to AHS with social needs

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Assist AHS consumers with basic resource information and navigation Partnership with over 15 community-based

• rganizations

Patient Placement Story

In early 2018, a 60 year old male patient was admitted to Highland Hospital with a right hip

• fracture. The patient also found to be cognitively impaired and had been living in his car. At

Highland, the patient was able to recover from their injuries, but when it came to discharge him, because he was no longer acutely ill, there was no suitable placement. He needed some assistance after discharge to ensure that he would not be readmitted. The patient was homeless and was unable to care for himself independently. He had some impairment, but it was not so severe that he met the criteria for skilled nursing care. The patient was referred to an exhaustive list of placement options and was repeatedly rejected for either insufficient medical reason for placement or limited income. The patient‘s ability and disability put him out of reach for appropriate post-acute care. The patient had family in the area, but they lacked the resources (i.e., appropriate housing) to meet his care needs. The Alameda County HCSA worked with Highland Hospital and brought in its partnership with East Bay Innovations to provide support and housing for the patient and his family. The patient, his daughter and grandchildren are now part of the patient’s care team, have housing and live under the same roof. This was our first success story for the Alameda County HCSA and AHS collaboration to solve placement barriers for medically complex patients. This patient remained hospitalized at Highland for over 200 days before they were safely discharged into housing before the 2018 Thanksgiving Holiday.

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HealthPAC Risk Stratification

 Health Program of Alameda County (HealthPAC) is a health access program for uninsured residents  In 2017, used eligibility, medical claim, pharmacy claim and lab data from AHS and stratified data placing patients into priority, high, moderate, low and no known risk categories (used Conifer Insight Tool)  Two areas were prioritized for improvement – outreach programs for breast cancer screening and colon cancer screening  AHS implemented comprehensive team-based programs across all AHS ambulatory care sites to improve screening rates for these conditions  Impact of efforts – exceeded 90th percentile for breast cancer and closed the gap to the 90th percentile by 38% for colorectal cancer

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