SAO

Steve BarlowCMO SelectHealth

September 2012

Goal for System

CPI + 1%

CPI +1%

Starting April 1, 2016 premiums for large employers will be no more than CPI +1% for the same benefitsCurrent LE premium $250.00 pmpmLE currently 46% of SelectHealth business

Structure

• Three main committees to organize the work– Flow of Funds– Redesigning Care– Patient Engagement

Shared Accountability…Realizing the Triple Aim

Redesigning Care•Evidence-Based Best Practice

•Integrated Care Management

•Personalized Primary Care

•Telehealth

•Med Management

•Medical Technology

Aligning Incentives•Payer Contracting

•Payment Models

•Benefit Design

•Pricing Transparency

Engage Patients•Shared Decision Making

•Health Literacy

•Health Promotion and Wellness

Flow of Funds

• Initiatives that align with different payment mechanisms– Efficiency Initiatives

• Fee for Service– Cost per case initiatives

• DRG’s• Fixed pricing outpatient services

– Population management initiatives• Global Risk Contracts

Managing the Transition

PopulationIntra

Case

Developing Medicare, Medicaid

Convert Commercial to Fixed Pmt Convert Commercial to

Prepayment

Dollars in millions

CPI+1% will require work with

non-Intermountain providers

0

20

40

60

80

100%

Uses of SelectHealth premium

IP Hospital

Intermountain

Non-Intermountain

OP Hospital Professional Pharmacy

24% 16% 29% 11% 9% 8% 3%

% of

premium

Getting to CPI+1%

Lower RevenueRate Increases

Managing Utilization Growth

Net Revenue in millions

5,095 4,700

Managing Utilization

Baseline 3,478.9Population 298.1Inflation 574.3Utilization 542.8 → 264.5 (278.3) Other 200.4 → 83.7 (116.7)

Utilization

Inflation

Utilization

Other

Clinical Program Goals

• Discuss 2013 Operating Budget targets– Move to DRG payments for top ten

commercial payers– Focus on intra-case utilization for

2013 - 2014

• Discuss how we can work together to identify and prioritize intra-case utilization opportunities

Establish Care & Treatment Standards

Clinical Program/Service

Potential Opportunities Identified

Behavioral Health Reducing staffing model variation and hot spotting for patients with high readmission rates.

Cardiovascular Examine intra-case variation within the Isolated CABG, Isolated valve, and CABG +1 Valve DRGs. Look at physician practices driving the variation

Imaging Examine intra-case variation within DRGs with highest imaging utilization. Look at physician practices driving the variation

Intensive Medicine

Examine intra-case variation within the Sepsis and Pneumonia DRGs. Look at physician practices driving the variation and adherence to current protocols.

Laboratory Examine intra-case variation within DRGs with highest laboratory utilization. Look at physician practices driving the variation. Right-sizing hospital labs vs. Central Lab.

Peds Appropriate step down from NICU to Med/Surg. at PCMC, centralized vs. distributed NICU model, Asthma care protocols to reduce readmissions.

Pharmacy Appropriate transition to oral drugs from IV as soon as is clinically acceptable.

Primary Care Examine the impact on cost per case for patients associated with Mental Health Integration.

Respiratory Determine impact on utilization of "evaluate and treat" protocols implemented at IMED.

Surgical Services SPRING initiative to reduce supply expense. Examine utilization variation using the Surgical Cost Analysis Tool (SCAT).

Women's and Newborns

Determine financial impact of shortening length of labor by shortening the time of admission to pitocin, amniotomy, and delivery.

Detail: Care Delivery

Key Observations• Lack of clarity on intra-case vs.

population utilization initiatives• Very few intra-case initiatives clearly

defined and scoped– Data analyses requested

• Clear need for accurate financial data to link with clinical data

• Concerns surrounding:– Measuring and budgeting financial outcomes– Variation in costing data– Resources required to do to the work

Clinical Program Goals 2013

• Behavioral– Reduce staffing model variation– Hot spotting patients with high

readmissions

• Cardiovascular– Intracase variation CABG, Valve,

CABG +one valve DRG’s– Physician practices driving variation

CV Activity ResultsHyperglycemia

2004 Baseline 2.88% mortality2005 Mgmt Protocol for Cardiac Surgery .92% mortality

ACS Management2005 Guidelines Development 8.6% mortality; 1mth Readmit 7.5%2006 PCI<90min 7.5%; 6.1%2007 PCI<90min for non-cath lab hospitals 7.5%; 6.2%2008 7.2%; 5.9%2009 PCI<90min >75% of patients 6.9%; 5%2010 7%; 3.9%

Cardiovascular Clinical Program

Clinical Program Goals 2013

• Imaging– Intra-case variation with DRG’s with

highest imaging utilization (physicians driving variation)

• Intensive Medicine– Intra-case utilization in Sepsis and

Pneumonia DRG’s (physician practices and protocol adherence)

Intensive Medicine Activity ResultsVent/VAP

2004 Measure Vent Days 10 cases of VAP per 1000 vent days2005 Develop Vent Bundle 6 cases 2006 Drive Compliance w Vent Bundle 80% 5.5 cases2007 Drive Compliance w Vent Bundle 90% 2.7 cases2008 Drive Compliance w Vent Bundle 92% 2 cases2009 VAP not a Board goal 3.6 cases2010 VAP not a Board goal 3.5 cases

Sepsis 2004 Baseline 22% mortality rate; <5% bundle compliance2005 Develop Sepsis Measures 15% mortality; 27% compliance2006 Compliance w Resuscitation and Maintenance Bundle 90% 14%; 28%2007 No Goal 13%; 37%2008 Compliance w Lactate and Glucose Control 85% 13%; 50%2009 Full Sepsis Bundle Compliance 60% 8%; 70%2010 Full Sepsis Bundle Compliance 77% 7%; 72%2011 No Goal

*Source: Sum of Vent Days Total Count from IMCP_ICU_VENT_FCILTY_SMRY**Source: Quality Database - query as developed by the Intensive Medicine clinical program to extract all VAP patients

YEARVent Days*

VAP Patients**

VAP Rate per 1000 patient

VAP days

Increase or Decrease from baseline (2004)

VAP rate

Economic Impact of VAP Rate

2004 12,291 82 6.7 2005 12,291 60 4.9 22 1,285,086$ 2006 17,443 155 8.9 (39) (2,256,388)$ 2007 16,705 97 5.8 14 843,964$ 2008 17,288 73 4.2 42 2,473,074$ 2009 16,053 82 5.1 25 1,466,071$ 2010 12,349 77 6.2 5 314,668$ 2011 11,092 63 5.7 11 642,591$

7-Year Total 82 4,769,064$

Intensive Medicine Clinical Program

Clinical Program 2013

• Laboratory– Intra-case variation within DRG’s highest

lab utilization (physicians driving variation)

– Right-sizing hospital and central lab

• Peds– Stepdown from NICU to Med/Surg– Centralized vs. Regional NICU– Asthma protocols to prevent readmissions

Clinical Programs

• Pharmacy– Appropriate transition from IV to oral

drugs

• Primary Care– Impact on cost per case with mental

health integration

• Respiratory– Impact of evaluate and treat protocols

Clinical Program Goals 2013

• Surgical Services– SPRING initiative to reduce supply

expense– Blood Utilization

• Women and Newborn’s– Shorten length of labor by shortening

the time of admission to pitocin, amniotomy and delivery

Next Steps• Resources

– Short term: recruit resources to support the evaluation and prioritization process

• Process– Short term:

• Begin evaluation and planning process for SPRING initiative.

• Pull costing data for key processes/APRDRG identified by Clinical Programs/Services

– Long term: Develop structure, tools and competency to support key process elements