Defining the Value of GIM in Academic Health Systems –

Leadership Perspectives

Defining the Value of GIM in Academic Health Systems –

Leadership Perspectives

ACLGIM: Training & Leadership InstituteApril 24, 2013

Andrea Sikon, M.D., F.A.C.P.Chair, Department of

Internal Medicine and GeriatricsMedicine Institute

ObjectivesObjectives• The Changing Healthcare Landscape

- Drivers of volume to value- Evolving care delivery models

• Academic medical centers• Where GIM fits in

- Our Cleveland Clinic (CC) story• Threats and opportunities for Primary

Care

Costlier Care is Often Worse CareCostlier Care is Often Worse Care

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“A Strategy for Health Care Reform—Toward a Value-Based System”

“A Strategy for Health Care Reform—Toward a Value-Based System”

Value = Quality/Cost

Michael PorterNEJM 2009; 361:109-112

Value of Primary Care: Existing evidence

Value of Primary Care: Existing evidence

• ↓hospitalization rates• Lower costs• ↑health outcomes

- ↓cancer, cvd mortality- Nation

• ↓premature births, deaths from treatable conditions, and post neonatal mortality.

• ↑specialists = ↑per capita Medicare spending

• Vast majority of Americans prefer a sustained relationship with a PCP

http://www.acponline.org/advocacy/current_policy_papers/assets/dysfunctional_payment.pdf. 2006. Accessed 4/20/13.

Today Care is Fragmented, Variable and DiscontinuousToday Care is Fragmented, Variable and Discontinuous

Recovery and Rehab

SNF

Outpatient Rehab

Home

Wellness / FitnessCenter

Retail Pharmacy

PhysicianClinics

Diagnostic /Imaging Center

Urgent Care

Surgery Center

Community-Based CareAcute Care

Hospital

IRF

NEJM 2009; 361:109-112

Volume-Based Value-Based

Payment Fee-for-Service Outcome Based

Incentives Volume Value

Focus Acute Episodes Populations

Role of the Provider Single Episodes Care Continuum

Information Retrospective Predictive

The New WorldThe New World

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“Care Transformation” is Critical“Care Transformation” is Critical•Transform the clinical operations

•Assemble the right care team

•Reward added value with sustainable payment models

•Support with the correct Analytics

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There’s No Place Like a “Medical Home”

Physician Directed Practice

Comprehensive and Coordinated

Care

Payment for Added Value

Enha

nced

A

cces

s

Patient Engagement

Safety and Quality

Treatment of Patient as a

“Whole”

Step 1: Transforming Operations

http://www.pcpcc.net/guide/benefits-implementing-primary-care-medical-homeBenefits of Implementing the PC PCMH: A Review of Cost & Quality Results

Step 2: Assembling the Right Team: Where are AMCs & what

is the role of GIM?

ACOs and AMCs ACOs and AMCs +

• Existing relationships w/ multispec groups

• Market leaders• Strong network w/

community hospitals/physicians

• Advanced IT integration

• Clinical quality tracking

-• Subspeciality

dominated• Highest cost• Culture- hierarchal

& silos• Must strengthen

ties w/ community practices

• Increase agility• Reward system

NEJM 2011:364e11NEJM 2011:e12 (1-3)

The Right Team:What is the role of Primary Care?

ACP IOM.edu/bestcare

Step 3: Reward added Value with Sustainable Payment Models

Step 3: Reward added Value with Sustainable Payment Models

Enhanced fee-for-service

Additional PMPM

Pay-for-performance / Gainsharing

Global payment

• Recognizes additional billing codes for services

• Recognizes additional care provided for each patient

• Covers all patient primary care need for a set period of time

• Rewards high quality / low cost care with bonuses

Evaluate a variety of payment options and pursue a multipronged approach with the payers

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Step 4: Support with Correct Analytics/Health Info. Technology

Accuracy, usability, timeliness

Value is the Centerpiece of Cleveland Clinic Strategy…Value is the Centerpiece of Cleveland Clinic Strategy…

Cleveland Clinic Health System

Cleveland Clinic Health System

• 2,800 salaried physicians• 33,000 employees• 120 medical specialties & subspecialties• Locations:

- Main campus- 8 community hospitals - 18 Family Health Centers in NE Ohio- Florida, Las Vegas, Canada, & Abu Dhabi

• 4 million visits in 2010• Patients from every state & > 100 countries

CC Mission & CultureCC Mission & Culture• “Better care of the sick, investigation into their

problems and the further education of those who serve” -- CC Founders

• “Striving to be the world’s leader in patient experience, clinical outcomes, research & education”

• “Quality, innovation, teamwork, service, integrity, compassion”

• “Patient’s First” • Transparency

Unique factors at CCUnique factors at CC

• Physician governance• Serving Leader foundation• Group practice- salaried Staff model • Robust professional development• “A Learning Health Care System”- IOM1

- Continuous Improvement support

1-Iom.edu/bestcare

Cleveland Clinic Integrated Care Model: A Value-Based Patient-Centered Model of CareCleveland Clinic Integrated Care Model: A Value-Based Patient-Centered Model of Care

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• Personalized

• Patient-focused

• Integrated

• Continuous

• Transcends time, physical location

• Right care, right place, right time

• Primary care and Specialty Care

HCR at CC: Making it happenHCR at CC: Making it happen

• Executive Team (ET) buy in• Operationalizing the plan

- Institutional• Developing the infrastructure

- Local• Medicine Institute= Primary Care

Creating ET buy in:The Primary Care value pivot

Creating ET buy in:The Primary Care value pivot

• Key institutional leaders are PCPs & national leaders- MI, Community Hospitals Presidents,

Quality, IT, Business Intelligence & Medical Operations

• Advisory Board input• Government relations department• Employee Health Plan- Mini ACO 80K lives• 3rd party payer interest

Institutional:Developing infrastructure

Institutional:Developing infrastructure

- Institute reorganization- 2008- Full CCHS integration- “One CC”

• Community Phys. Partnership- Employed model

• EHR full integration & Optimization CMIO• Supply chain consolidation• Centers of excellence

- Quality Alliance- Data and analytical tool development- Chief strategy officer position created

Operationalizing the Plan: Local

Operationalizing the Plan: Local

• Expanded Primary Care at FHCs- 1996• Longstanding quality metrics

- -> Transparency mid 2000s• Medicine Institute (MI) chair leading

institutional Value Based Care effort• MI planning team with local site leaders

The Cleveland ClinicWho we are… Medicine Institute

The Cleveland ClinicWho we are… Medicine Institute

• Five clinical departments- Family Medicine- Community Internal Medicine- Internal Medicine and Geriatrics- Infectious Disease- Hospital Medicine

• 329 Physicians: 214 Primary Care (155.4 FTE) Physicians

• 29 Sites, 40 practices for Primary Care• 550,000 visits• 10 sites received NCQA level 3 recognition in 2010

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Care CoordinatorWorkflow

VBC Population Management Guidance TeamChairman – David Longworth, MD

Cleveland Clinic – Value Based Care

Evaluation Team Independence Site TeamStrongsville Site Team Main campus Site Team

Clinical PharmacyWorkflow

Metrics:• Access, quality, patient experience,

cost, ER visits, hospital admissions, hospital-re-admissions, provider satisfaction

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Medicine Institute Population Management Projects in 2012Medicine Institute Population Management Projects in 2012

TeamCare

(Strongsville FHC)

MD-RN model

(Main Campus G10)

MD-APN-MA model

(Independence FHC)

• Embedded chronic disease managers• Embedded pharmacy support of different

intensities • PCMH tenants: Top of license, pre-visit planning• IM longitudinal resident clinic re-design

Initial Projects: 60,000 lives, 20% of providers

Early results…Early results…• Caregivers highly engaged• Many positive anecdotals from patients• No post implementation data yet on

cost or utilization from payers (-EHP)• Quality metrics strong• Hospital re-admissions fell 15% in third

quarter 2012 at pilot sites (7.7%-27.7%)• TeamCare has enabled providers to

increase daily visits from 20 to 26-32

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Ongoing workOngoing work• Extend practice redesign to all PC sites• Next steps:

- Institutional level:• Institutional Care Paths• Ever-evolving data/analytic tool

- Local level: phased approach• Behavioral health• Community services• PCMH neighborhoods

(sub-specialities)

Prepping for successPrepping for success• Setting the culture locally

- Kick-off event- Change management training for all

• Űber communication!• Maximally empower front line • Metrics & Outcomes sharing:

- Short term and long term metrics- Add non-traditional methods

Lessons being learnedLessons being learned

• Common thread= Relationships • Rapid process cycle continuous

improvement• Lots of recognition • (Need for breaks!)

Threats for Primary CareThreats for Primary Care• Rapidness of change• Developing Infrastructure

- Failure to fully integrate- Getting things to front line users- Data difficulties- too little and too much…

• Information overload - Numerous metrics- Rapidly deepening clinical knowledge base- New skills - Process adaptation

Threats for Primary CareThreats for Primary Care

• How to fund changes now?- Need to operationalize new models

before full reimbursement transition• Timing/Failure of true funding transition

Threats for Primary CareThreats for Primary Care

• Government oversight- Much undefined in ACA- Multiple agencies/variable definitions- State variation

• Patient activation- Understanding implications of value

over volume shift- “Skin in the game”- Tools/resources

Opportunities forPrimary Care

Opportunities forPrimary Care

• Team skills- Interdisciplinary training & leadership skills

• Redesign operations to optimize Relationships: - Top of license preceded by trust

• Community integration• Enhanced predictive analytical

capabilities

Opportunities forPrimary Care

Opportunities forPrimary Care

• Rethink training- AAMC’s Healthcare Innovation Zones

(HIZs)- Expand PCP training skillset:

• Teamwork- interdisciplinary• Leadership• Quality• Continuous improvement• Health care policy

JAMA. 2010;303(9):874-875. doi:10.1001/jama.2010.224.

Imperatives for transitionImperatives for transition

• Innovation needed- New training, technology, systems

changes• Culture shifts True teamwork across

disciplines & beyond, pool resources• No one sized fits all approach• Manage expectations • Continued sharing of best practices

Future research focusesFuture research focuses

• Comparative effectiveness• Optimal educational techniques

(exponential skills, interdisciplinary)• Predictive modeling• Decision support• Patient activation• Practice redesign• Transitions of care• Optimal determinants of quality

Opportunities for SGIM/ACLGIM

Opportunities for SGIM/ACLGIM

• Continued sharing of best practices• Continued skill development:

• Teamwork/interdisciplinary, leadership, quality, continuous improvement, change management, health care policy

• Extension to trainees • Continued Health Policy advocacy

GIM is well poisedGIM is well poised

• Diverse interests and skills• Essential foundation of care= PCMH• Already relationship-centered • We are educators and researchers• We can be the leaders of reform and

implementation

Resources for GIM & HCRResources for GIM & HCR• The Advisory Board: http://www.advisory.com/• Patient-Centered Primary Care Collaborative

(PCPCC) http://www.pcpcc.net/

• Institute of Medicine: The Learning Healthcare Systemhttp://www.iom.edu/Activities/Quality/LearningHealthCare.aspx

• American College of Physicians:- http://www.acponline.org/advocacy/where_we_stan

d/assets/i1-summary.pdf

“All our dreams can come true, if we have the courage to pursue

them.”

“All our dreams can come true, if we have the courage to pursue

them.”

Walt Disney

“Success is not final, failure is not final: it is the courage to continue

that counts.”

“Success is not final, failure is not final: it is the courage to continue

that counts.”

Winston Churchill

Thank you!Thank you!

• sikona@ccf.org

Questions and DiscussionQuestions and Discussion

Back-Up SlidesBack-Up Slides

Primary care-led clinical workforce

• Elevate PCP to “CEO” of care team

• Mobilize community workforce to extend care team reach

Patient engagement and

community integration

• Map services to population need

• Overcome non-clinical barriers to maximize health outcomes

• Integrate patient’s values into the care plan

• Use community stakeholders to connect patients with high-value resources

Information-powered clinical decision-making

• Use robust patient data sets to support proactive, comprehensive care

• Operate within an integrated data network

• Position a leader to merge data analytics with clinical care

3 Elements of Successful Population

Management

Remaining questions

Charity care at Cleveland ClinicCharity care at Cleveland Clinic

- Persons with incomes up to 400 % of Federal Poverty Level w/in 150 miles

- In 2009, $120 million 20% increase for 2010.

Institutes at Cleveland Clinic-Clinical

Institutes at Cleveland Clinic-Clinical

• Anesthesiology• Cancer (Taussig)• Children's Hospital and

Pediatrics • Dermatology & Plastic

Surgery • Digestive Disease• Emergency Services• Endocrinology &

Metabolism• Head & Neck• Heart & Vascular•

• Imaging • Medicine• Neurological• Ob/Gyn & Women's Health• Ophthalmology • Orthopaedics &

Rheumatologic• Pathology & Lab Medicine• Respiratory• Urology & Kidneys• Wellness

Institutes at Cleveland Clinic-Non-Clinical

Institutes at Cleveland Clinic-Non-Clinical

• Arts & Medicine• Education• Nursing• Philanthropy Institute• Quality & Patient Safety• Regional Operations• Research (Lerner)