Population Health: A Consumer Driven Business Imperative–Provider Contracts (Physicians, NP/PAs)...

David James MD, JD, CPE

Population Health: A Consumer Driven Business

Imperative

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Population Health: Changing Market Conditions

Changing Market Discussion Areas:

➢ Post Macra World

➢ Advanced Alternative Payment Models

➢ High Deductible Plans

➢ The Population Health Management as a Business Model

➢ The Rise of the Consumer

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$$$$$$$$$

$$$$$$$$$

$$$$$$$

$$$$$

$

MLR = FFS + VB + Bundled/Cap Administrative

Costs

PCP CARE

MANAGEMENT

FEES (PMPM)ADMIN

COSTS /

CONTINGENCY

Fee-for-Service

Schedule

VB + Bundled/Cap

• Primary Care MDs

• Key Specialists

• Consulting

Specialists

• Hospitals

• Ancillary Providers

• Rx/Lab

• Other

CLINICAL

QUALITY

TARGETS

PATIENT

SATISFACTION

TARGETS

PLAN/CIO/ACO

SHARED

SAVINGS

$

Targets

Achieved

Top Line “Premium Revenue”

Provider Revenue Stream:In a Post Macra, Value Based, aAPM World

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MACRA:

Disruptive by design

MACRA is a game changer…the new law aims to fundamentally

change the health care payment system and drive the delivery of

health care in the futureMACRA offers significant

financial incentives to

participate in risk-bearing,

coordinated care models

and to move away from the

fee for service system

Bipartisan bill passed in

2015 to replace Medicare

sustainable growth rate

(SGR)

Combines PQRS (quality

reporting), VM (Value

Modifier) and MU

(Meaningful Use)

into one program

MACRA establishes a path

toward a new payment

system

Payment systems under

MACRA:

MIPS (Merit-Based

Incentive Payment System)

aAPM (advanced

Alternative Payment

Models)

Final rules to be released

by Nov 1, 2016

Data collection

(performance period) to

begin January 2017, with

payment changes

beginning January 2019

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MACRA:“MIPS” Reporting

• Like MU

• Report measures of patient engagement & information exchange

• Like PCMH

• Report on practice activities – over 90 to choose from

• Like PQRS

• Report 6 measures

Quality

(50%)

Resource Use

(10%)

Clinical Activities

(CPIA)

(15%)

(Resource

Use increases

to 30% by

2019)

(Quality

decreases to

30% by 2019)

Advancing

Care Info

(ACI)

(25%)

• Like VBPM

• Total per capita cost

calculation, Part A & Part

B, attributed to physician

(ties physician to hospital

cost)

5

- 6 -6

Maximum Incentives: Only for High MIPS Performers

- 7 -

Implications of MACRA:Private Physicians

7

- 8 -

Timeline for MACRA Implementation

Source: Public Law 114-10 (April 16, 2015)

8

Population Health Management:Clinical Integration as

a business model

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Changing Market Conditions:Population Health Management Framework

Health Promotion

• Consumer Engagement

• e-Health

• Wellness / HRA

• Occupational Medicine

Prevention & Disease Mgmt

Population Health

Management Platform

The “Triple Aim”

Upstream Factors

• Socio-Economic

• Physical Environment

Factors

Individual Resilience Medical Outcomes Community Health

Outcomes• Genetic Factors

• Behavioral Factors

• Physiologic Factors

• Spiritual Factors

• Quality of Care

• Experience of Care

• Total Cost of Care• Health Function

• Mortality

Customer

Requirements

• Health / Well Being

• Performance Contracts

• Affordability

HO

W?

Abstracted from IHI

WH

AT

?

WH

Y?

• Performance Based Contracts

• PCMH Domains, EMR

• Stratified Care Management

• Quality Management Systems

• Performance Management

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Customer Requirements (Measures)

Patient

• Health, Safety, Compassion, Transparency

• Access, Convenience,Time

Primary Provider

• Strong performance based Payer/Employment contracting

• Clinical/Operational Practice Support

Employer/Payer

• Manageable Cost PMPM

– PCP Sensitive Admissions

– ED utilization

– High end testing/diagnostics

– Specialty referrals

– Cost/DRG

– EBC/formulary adherence

Community

• Manageable Per Capita Cost

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Health Promotion


• e-Health

• Wellness / HRA



Population Health

Management Platform


Upstream Factors

• Socio-Economic


Factors






• Quality of Care



• Mortality

Customer

Requirements



• Affordability

HO

W?

Abstracted from IHI

WH

AT

?

WH

Y?






- 13 -

Upstream Factors(Measures)

Socio-economic Factors

• Community Health Assessment Measures

– City/County level indicators:

• Insurance Coverage

• Preventative care delivery rates

• Demographic stratification

• Government Relations Measures

• Community Agency / Stakeholder Measures

• Community project implementation / deployment Measures

Physical Environment Factors

• Community Health Assessment Measures

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Health Promotion


• e-Health

• Wellness / HRA



Population Health

Management Platform


Upstream Factors

• Socio-Economic


Factors






• Quality of Care



• Mortality

Customer

Requirements



• Affordability

HO

W?

Abstracted from IHI

WH

AT

?

WH

Y?






- 15 -

Individual Resilience Factors(Measures)

Genetic Factors

– Screening Rates

– Prevalence Rates

Behavioral Factors

– Modifiable Risk Factors

• Tobacco, Ethanol, Activity, Diet

– HRA Results

– Online wellness plan enrollment

– Compliance Measures

• Payer/Employer Incentive Plans

• Preventive Care

– Immunization rates

– Screening rates

– Exams

• Chronic Disease

– Exam, Tests

– Medication Adherence

Physiologic Factors

• Community Health Assessment

– Prevalence/Age of onset:

• HTN; Lipid disorders Obesity,

Diabetes, CAD . . .

Spiritual Factors

– Affiliation rates

– Faith based community support

activities

– Chaplaincy

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Health Promotion


• e-Health

• Wellness / HRA



Population Health

Management Platform


Upstream Factors

• Socio-Economic


Factors






• Quality of Care



• Mortality

Customer

Requirements



• Affordability

HO

W?

Abstracted from IHI

WH

AT

?

WH

Y?






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Intermediate Medical Outcomes (Measures)

Disease Burden

• Preventive & Chronic Disease Management Outcomes (MIPS Domain 1)

– HEDIS/GPRO/PQRS/Payer “ACO Measures of Excellence”

• BMI, HTN, Lipids, Medications, HbA1c, Cancer screens…

• Behavioral Health Management Measures

– Depression, Anxiety

Experience of Care

• Patient Satisfaction “CAHPS” (the Care Giver)

• Workforce Satisfaction – Employment engagement score relationship

• IOM Key Dimensions (the Care Given)

– Safe: adverse events/injuries, mortality

– Effective: successful outcomes

– Timely: access…. time as a commodity

– Efficient: Cost effectiveness

– Pt. centered: Engagement

– Equitable: Community Benefit

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Health Promotion


• e-Health

• Wellness / HRA



Population Health

Management Platform


Upstream Factors

• Socio-Economic


Factors






• Quality of Care



• Mortality

Customer

Requirements



• Affordability

HO

W?

Abstracted from IHI

WH

AT

?

WH

Y?






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Community Health Outcomes

Health Function


– Global single question

– Multi-domain rollup assessments

– Health Life Expectancy (HLE)

Mortality


– Overall Life Expectancy

– Mortality Ratios

– Years of healthy life lost

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Health Promotion


• e-Health

• Wellness / HRA



Population Health

Management Platform


Upstream Factors

• Socio-Economic


Factors






• Quality of Care



• Mortality

Customer

Requirements



• Affordability

HO

W?

Abstracted from IHI

WH

AT

?

WH

Y?






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Health Promotion Portfolio

Product / Service / Program Solutions

• Customer Engagement / Self-Management Tools

– Patient Portal

• Access, Education, Informed Consent, Scheduling, Registration / Demographics, Retail

purchasing, Web Based Care Navigation, Personal Health Record/Monitoring

– e-Health

• Integrated home / mobile device applications

• Health promotion

– Employer/Insurer Based Programs/Clinics/Navigation

• Wellness / Prevention Programs

• HRA’s, Biometrics

• Occupational Medicine/Total Employee Health

- 22 -


Health Promotion


• e-Health

• Wellness / HRA



Population Health

Management Platform


Upstream Factors

• Socio-Economic


Factors






• Quality of Care



• Mortality

Customer

Requirements



• Affordability

HO

W?

Abstracted from IHI

WH

AT

?

WH

Y?






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Prevention & Disease Management Portfolio

• Performance Based Payer Contracts – Employer/Insurer based Benefit Designs, aAPMs

– PND/CIN Management, Contracting Requirements

– TPA/Claims Administration

• Performance Based Provider Contracting

– Provider Contracts (Physicians, NP/PAs)

– Provider Compacts (Physicians, NP/PAs

• PCMH– Implement, Operationalize, achieve NCQA Domains

– Consumer Driven Care: Urgent Care, Retail Care, Virtual Care

– Clinical Access Center/Nurse Triage

– Behavioral Health Integration

– COEs, PCMH-N

• EMR Deployment MIPS Domain 2

– End User Experience Optimization

– Decision Support

– MU attestation (ACI)

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Prevention & Disease Management Portfolio

• Quality Management Systems (DMAIC Model) MIPS Domain 1, 3

• Data Analytics (Quality/Cost)

• Actionable End User Reporting

• Clinical Protocol/Process/Supply Chain Mgmt (LEAN 6sigma)

• CIN Utilization Decision Support/Management

• Risk Stratified Care/Case Management (QMS Required) MIPS Domain 4

– Primary/Ambulatory Care Mgmt(Low/moderate Risk: Provider Patient Panel)

– Point of Care Gap Closure

– CDI/HCC

– Outreach

– Ambulatory Services Navigation

– Pre/Post Acute Care Mgmt (Moderate/Complex Risk: ACO/Insurer Member Panels)

– Complex Case Mgmt/Outreach, Virtual Monitoring

– Home Care, Hospice, LTC, PCP Navigation

– Acute Care (High Risk: )

– Hospitalist Medicine/MDR Programs/PCMH Integration

– Acute Care/Transition Care Navigation


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Health Promotion


• e-Health

• Wellness / HRA



Population Health

Management Platform


Upstream Factors

• Socio-Economic


Factors






• Quality of Care



• Mortality

Customer

Requirements



• Affordability

HO

W?

Abstracted from IHI

WH

AT

?

WH

Y?






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Population Health Management (as an MSO)

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Portfolio of Services

Health Promotion

Patient Monitoring

ProgramsWellness

HRA eHealth Education

Prevention / CDM

PHM Readiness

AssessmentPCMH

Care

Navigation

EMR,

PM Systems

Data

Analytics

Performance

Contracts

Value Based

Benefit

Designs

Utilization &

Case

Management

TPA

Services

Preventive

Care

Management

Chronic

Disease and

Medication

Management

Customers

1. Physicians, IPAs, ACOs

2. Patients

3. Employers, Payors

4. Acute Care

Service Components

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$

Population Health ManagementClaims Data EMR Data Managed Care Operations

Smart Registries Risk Stratification Data Analytics

WellnessDisease Management

Low / Rising Risk

ModerateRisk

High Risk End of LifeBu

sin

ess

Inte

llige

nce

Outpatient / Ambulatory Care Management Inpatient / Acute Care Navigation Management

Every DayWell

• PCMH, SM&R

• COE’s

• Ancillaries

• Clinical Access Center

• TeleMed

• Home Care

• Monitoring

• DME

• Senior Living• LTC• SNF• LTAC

IRF, TIRR ED Hospital Hospice

Gro

un

d O

per

atio

ns

• PCPs

• Extensivists

Consumer Engagement Provider

Platform (CS, ES)

Primary Care (PCPs)

Specialty Care (OP)

Hospitalists / Intensivists

ED, PM&R, Specialists (IP)

Supportive Medicine

& Hospice Care

Member Health Management

$$ $$$ $$$$ $$

Dashboards Reports Registries Communications Targeted Interventions Focused Outreach

Clinical Ops Specialists / Health Navigators & Coaches / My Health Advocate Case Managers / Social Workers / Discharge Planners / UR / CDI

Population Health Management Paradigm:Right Care, Right Place, Right Price

Consumer Solutions for a

Primary Care Continuum“Taking the Walls off of the Medical Home”

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Consumer Solutions – Environmental AssessmentAmong Many Consumer Demands, Three Are Most Pressing

Competitive Ambulatory Assets Meet Patient Demands

Top Priorities for Meeting Consumer Preference

$Affordability On-Demand Access Tailored Service

▪ Reasonable price

compared to similar

options

▪ Clear pricing to

streamline payment

▪ Guidance on which

sites are most

affordable

▪ Immediate availability

▪ Broad range of hours

open

▪ Rapid completion of

service

▪ Geographic proximity

to home, work,

errands

▪ Comprehensive visit

length

▪ Provider interaction

matches expectation

▪ Delivery options

tailored to specific

need

30Source: Advisory Board

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Consumer Solutions – Environmental AssessmentThe Emerging Era of Consumer-Driven Growth

Converting Consumer Preference into Profitable Growth

Maintaining

Share at Risk

Growing as a

Coordinated Network

Preserving Share

Through

Affordability

I

Driving Volumes

with On-Demand

Access

II

IIIUnlocking Value

Through Tailored

Service

1 Attracting Price-Sensitive Consumers

with Competitive Offerings

2 Generating Direct Revenue

From Access Points

3 Converting Initial Visit

To Future Revenue

4 Embracing Premium

Payment Models

5 Accommodating Excess

Primary Care Demand

Consumer

Demands

31

Gro

wth

Source: Advisory Board

- 32 -

2 Million

Covered

Lives

Consumer Solutions – Strategic Intent

Grow Covered

Lives Under Management

Retain Patient within the System

Increase Consumer

Engagement

Lower Total Cost of Care

32

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Environmental Assessment:The “Consumer Driven” Medical Home

Consumer ACCESSPCP

PCMHSpecialists,

Hospitals,

& Facilities“extended hours”

ACCESSConsumerPCP

PCMHSpecialists,

Hospitals,

& Facilities“extended hours”

“Bricks”▪ CCC▪ Urgent Care▪ Retail▪ Employer Solutions

“TeleFix”

Clinical AccessCenter

▪ Scheduling/Referrals▪ Nurse Triage▪ Telemedicine/Video

“Clicks”“EveryDay Well”

▪ Web Portals

▪ Device Apps

KEY TRANSITION

CustomerDirected

MHDirected

From Non Discriminating

To Loyalty

33

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Consumer Solutions – Tactical Infrastructure

34

Bricks• PCMH Clinics

• Convenient Care Centers (CCC)

• Urgent Care Clinics (UCC)

• Retail Care Clinics (RCC)

Clicks• Patient Portal

• Open Access Scheduling (ScheduleNow)

• Apps

• “EveryDay Well” Umbrella Brand

TeleCare• TeleCare Center

(TCC)• Centralized

Scheduling

• Clinical Support –RN Triage & Care Coordination

• Telemedicine

• Patient Concierge Services

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwii4MC-9prKAhXL5SYKHag-A7sQjRwIBw&url=http://www.allyhealth.net/telemedicines-popularity-grows/&psig=AFQjCNHRUgaj4nRxjrKamBhC-ZjEbcSXNg&ust=1452366822862186

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7

→ Insurance Companies

→ Urgent Care Facilities

→ Media

→ 3rd Party Stakeholders

→ Employers

Consumer Solutions – Tactical Infrastructure“Bricks” Urgent Care – The Retail Revolution

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiG2JmlsZvKAhVHKGMKHe4IALgQjRwIBw&url=https://www.practicematch.com/physicians/job-details.cfm/472715&bvm=bv.111396085,d.eWE&psig=AFQjCNGJEvKuuAZdkNCnWbv7Jsf496rbiQ&ust=1452382676124908

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➢ IT Integration▪ HIE

▪ ScheduleNow

➢ ACO Integration▪ CPC

▪ Adult and Pediatric Protocols

➢ Clinical Operations▪ Exclusive MD oversite

▪ APP Activities: float pools, CME

▪ Pediatric service

▪ Employer solutions

▪ Vaccines, VFC, flu shots

➢ Marketing▪ Co-branding re-launch

▪ Website & Collateral

▪ Campaigns

➢ Ambulatory Integration▪ Centralized Scheduling & PCS

▪ MHDL

Consumer Solutions – Tactical Infrastructure“Bricks” - Retail Medicine Partnership

Full Integration Workstreams

36

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Geographic PCMH - Growth Accelerator

Integrated Network - -

Growth & Brand Loyalty

Consumer Care Continuum – Payer/ACO Growth

Access & Panel - Growth Accelerator

Employer Solutions

– Occ Med Growth

Consumer Solutions – Tactical Infrastructure“Bricks” Urgent Care – 5 Strategic Growth

Imperatives

37

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjQppT5l5vKAhVHJCYKHaNAAPUQjRwIBw&url=http://www.psdgraphics.com/3d/seamless-chrome-metal-chain/&psig=AFQjCNHugrz-WSMM5rybQz4x3U3dr5icKA&ust=1452375851859012













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Consumer Solutions – Tactical Infrastructure“Bricks” Urgent Care – Primary Care Oriented

Advertising

38

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Consumer Solutions – Tactical Infrastructure“Clicks” - Digitization Transforms Industries

39

- 40 -Source: Accenture

Consumer Solutions – Tactical Infrastructure“Clicks” – Customers Demanding Digital Enablement

40

- 41 -41

Today

With no single user experience or identity, we offer:

• Too many logins

• Desktop-oriented design

• Up to 7 steps to access some features

Digital Engagement


- 42 -42

Spring

2017

Digital Engagement

• One login, one customer identity• A single, consistent user experience• Device agnostic Mobile-first design

• Customer-managed preferences• No more than 3 steps to access

a feature

Through Digital Engagement we’ll provide:


- 43 -43

IntroducingEveryDay Well

- 44 -44

IntroducingEveryDay Well

- 45 -

Consumers & Employers want

“on-demand” access to

Primary Care

By optimizing provider capacity, we can increase

panel size

Competitive market game-changer with

advent of virtualization

→ Cleveland Clinic licensed to practice

telemedicine in Houston

→ Walgreens to provide telemedicine in

25 states by end of 2016

Consumer demand for TeleCare will

increase proportionately with

improved technology

MHMG – Meeting the needs of our patients & providers

Consumer Solutions – Tactical Infrastructure“TeleCare” – Strategic Imperative

45

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjBg_HG56fKAhUISCYKHa1nAYoQjRwIBw&url=http://mhealthinsight.com/2015/05/22/what-can-a-doctor-do-for-a-patient-over-a-video-call/&bvm=bv.111677986,d.eWE&psig=AFQjCNEHPvGjmpafhbEUkEJiDzYxysDvBQ&ust=1452809558995508

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Practice Operation

Virtual Medicine

Clinical Services

Care & Case Management

Integration

✓ Centralized Scheduling & Ins. Verific.

▪ Patient Navigators

▪ Appox. 400K Calls Answered

Annually

✓ Outreach campaigns I.e. Superbowl VIP

Line, Medicare RAF Visit, etc.

✓ On-Call 24/7 Physician Answering Svc.

▪ 100% in-house – (Future State)

✓ Clinical Support:

▪ Rx refill and labs

▪ Health outreach campaigns

✓ Nurse advice/triage (After hour support )

✓ Virtual Visits

▪ Acute/chronic care

▪ Employer Solution

▪ Wellness

✓ Patient portal optimization

✓ Post-hospital discharge

PCP Follow Up Appointment Coordination

Pre/Post Acute Services Integration

46

Consumer Solutions:

Clinical Access Center

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1. Established MHMG Patients

2. Health Solutions

3. ACO

4. Employers

5. Open Market

Target Population (Phased)

➢Virtual Visits for

common ailments▪ Colds, coughs, sinusitis, UTI,

allergies, RX refills, etc.

Scope of Services

➢Bill to Insurance

➢Flat Rate Fee (if not a covered service)

Billing

➢HIPAA-compliant web-based solution▪ iPad, laptop & smartphone enabledInfrastructure

Consumer Solutions – Tactical Infrastructure“TeleCare” – Advance to TeleVideo

47

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• 6 (Tier 1) Clinics

− Integrated into the UCs

• 3 (Tier 2) Clinics

− Katy, Wharton, Sugar Land

• MH Occupation Health Clinics

(for MH employees)

• 8 Employer Onsite Clinics

• 54 Work Link Contracts

• 3 Clinics

− Memorial City

− The Woodlands

− Downtown

• 63 Employer Contracts

− Be Well @ Shell physicals

(1,500+ annually)

• Services to over 60+

employers in Houston

(including MH)

− Flu shots

− Biometric screenings

• 3 onsite employer based

RNs for chronic care, triage

and navigation

− Turner

− Friedkin

− SW Airlines

• 5 Employer Onsite Clinics

− Conoco

− Downtown

− Conroe ISD

− Phillips66

− Goodman

48

Primary

Care(onsite/near-site)

Health

and

Wellness

Employer Solutions: EveryDay Well, at Work

Occupational

Medicine(onsite/near-site)

Executive

Health

- 49 -

1. Environmental Assessment – B2B and B2C

▪ The payor market is rapidly changing with dramatic shifts in demands of

consumers, employers and insurers. As to our response, it’s not whether, but

how?; not if, but when?…

2. Primary Care/Medical Home 2.0 – Covered Lives

▪ Transformational approach to ambulatory primary care into a consumer

centric array of integrated, branded market channels designed to develop a

large and loyal customer base capable of efficient, stratified management:

right care, right place, right time, right cost.

3. Infrastructure Deployment – Market Segment Access

▪ Aged, Complex disease, Millennial, School age, Young parents, Sandwich

generation, underinsured.

▪ Consumer Engagement requires Market driven, tailored infrastructure.

49

Consumer SolutionsInnovating to Primary Care 2.0

Population Health: A Consumer Driven Business Imperative–Provider Contracts (Physicians, NP/PAs)...

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Transcript of Population Health: A Consumer Driven Business Imperative–Provider Contracts (Physicians, NP/PAs)...