The Paradigm Shift from Healthcare to Population Health

The Paradigm Shift from Healthcare to Population Health

Bechara Choucair, M.D.SVP, Safety Net and Community Health

@choucair#PPBmeeting

May 23, 2016

The Practical Playbook National Meeting

2©2016 Trinity Health - Livonia, Mich.

Healthcare trends that affect us all:An urgent need for a paradigm shift

3©2015 Trinity Health - Livonia, MI

U.S. – Spending More for a Shorter Life

The Cost of a Long Life

Per

Cap

ita S

pen

din

g

Avera

ge

Lif

e E

xp

ecta

nc

y

United

StatesLife Expectancy Per Capita Spending

(International Dollars)

1965: $42B1975: $134B

1985: $445B

1995: $1T

2005: $2T

2015: $3T

2020: $4.3T

2023: $5.2T

1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023

Historical Total Expenditures

Projected Total Expenditures


CMS Projects Health Expenditures to Grow at an Average

Rate of 5.7%,1.1% Points Faster than GDP Growth

To put this into context, if the 2013 US health care

spend of $2.793T was its own country it would be

the 6th largest country in the world by GDP, larger than the United Kingdom,

Russia, India or Canada

The health spend as a percent

of GDP is expected to rise to

19.3%up from 17.2% in 2012

by 2023


Perspectives

If health care costs in Medicare and Medicaid grow over the next

40 years as rapidly as they did over the previous 40 years, those

two programs will grow from under 5% of the economy today to

20% of the economy by 2050. That is the entire size of the

federal government today and is significantly larger than anything

else affecting the federal budget. It is the fundamental

long-term fiscal challenge facing this country.

“

”— Peter Orszag, former Director of the

Congressional Budget Office (CBO).

"Medicare and Medicaid

are the single biggest

drivers of the federal

deficit and the federal

debt by a huge margin."

— President Barack Obama

“Medicare and Medicaid will cost taxpayers

roughly $1 trillion this year alone. Unless

reforms are enacted, entitlements are on track

to consume all tax revenues before today‘s

25 year-olds are eligible for Medicare.

The status quo is empirically unsustainable.”

— Congressional Budget Office

There are 76.4 million Baby Boomers

according to the U.S. Census Bureau

For each of the next 20 years, 3 million

Baby Boomers will reach retirement age


The Upside of the Iceberg is Provider’s

Opportunity

By 2030, one in five Americans will be a

senior citizen and require significant health

care services.


Costs and Diagnosis of many Chronic Diseases are Expected to

Rise Driven in Part by the Baby Boomers Becoming Seniors

Between 2011 and 2029.

Hospitals performed twice

as many knee replacements surgeries as they did two decades

ago with replacement projected to

reach 3.5M per year by 2030

according to a 2012 JAMA study.

By 2029, when the last round of boomers

reaches retirement age, the number of

Americans 65 or older will climb to more

71 millionup from about 41 million in 2011

according to Census Bureau estimates.

73%increase

The number of new cancer cases could

increase 45% by 2030 according to a

2014 ASC Oncology study.

The cost of heart disease

in the U.S. will triple by 2030 according to a 2011

study commissioned by the

American Heart Association.

More than 50% of

Americans could have

diabetes or prediabetes

by 2020 according to a 2010

UnitedHealth Group study.


A pivotal transformative moment:The shift to population health is an opportunity we cannot afford to miss


The Marketplace Demands Fundamental Change

in How We Operate and What We Produce

Producer-Centered

People-Centered

Dri

vers

Retail Health Market

Value Networks

Transparency

Financial Incentives

Population

Value

Service

Volume

TOMORROWTODAY


Our People-Centered Vision Will Produce the

Population Health Dividend – Real Savings from the

Triple Aim

People-Centered Care

Time

Health C

are

Spendin

g

DIVIDEND

Note: Dividend similar to model cited in “Eliminating Waste in US Health Care.”

Berwick, Donald M., Andrew D. Hackbarth, "Eliminating Waste in US Health Care," JAMA 307, no. 14 (April 11, 2012): 1513-6.


Trinity Health:We are transitioning to a People-Centered System

30 million peopleWe serve diverse populations, with over

in our communities

As a mission-driven innovative health organization, we will become the national leader in improving the health of our communities and each person we serve.

We will be the most trusted health partner for life.


Our Vision: What We Aspire to Be … and What We Are Becoming …

Our Mission Drives Our Vision and Strategy

We, Trinity Health,

serve together in the spirit of the

Gospel as a compassionate and

transforming healing presence

within our communities.

Our Core Values

ReverenceCommitment

to those who

are poorJustice Stewardship Integrity

©2015 Trinity Health - Livonia, MI 13

Building a “People-Centered Health System”

together

Better Health • Better Care • Lower Costs

Efficient & effective caremanagement initiatives

Efficient & effective episode delivery

initiatives

Serving those who are poor, other populations, and impacting the social determinants of health

People-Centered Health System

Community Health & Well-being

Population Health Management

Episodic Health Care Management for

Individuals




Together




initiatives

Serving those who are poor, other populations, and

impacting the social determinants of health





Individuals

*Owned, managed or in JOAs or JVs.

**Operations are organized into Regional Health Ministries ("RHMs"), each an operating division which maintains a governing body with managerial oversight subject to authorities.

Our 21-State Diversified Network

Home Care & HospiceLocations Serving 116 Counties47

Continuing Care Facilities59PACE CenterLocations14

Hospitals* in 20 Regional Health Ministries**92

Employed Physicians 3.9K

Affiliated Physicians23.9K



We operate one of the largest clinical episode payment programs in the nation

• 43 Model 2 Bundled Payment for Care Improvement (BPCI) hospitals

• 13 Model 3 Skilled Nursing Facilities (SNF)

• 2 Comprehensive Joint Replacement (CJR) sites

• 22,400 total annual episodes for all three programs

BPCI

SNF

CJR


We are working to improve care across clinical conditions with 43 of 48 possible bundles

(in millions)

Total Program Size: $550m



Together




initiatives







Individuals

We continue to invest in increasing attributed lives and building capabilities

FY14 FY15 FY16

Total Number of ACOs, Attributed Livesand Annual Investment

Attributed LivesACOs Annual Investment

Since FY14, Trinity Health has invested over $90Min support of population health management efforts

Investments have promoted continual growth in both MSSP and commercial ACOs

$16.5M

$25.0M

$48.9M

34 ACOs

30 ACOs

11 ACOs

1,245,7501,121,000

640,000



Expanding ACO programs are the primary driver of APM growth

• 14 Medicare Shared Savings Program ACOs

• 5 markets partnering as a Next Generation ACO

• Participating in 98 non-CMS APM contracts

• 13.8K physicians participating in our Clinically Integrated Networks accountable for 1.2 million lives

Medicare Shared SavingsNext Gen ACO

Trinity Health made an initial investment in ACOs of $16.5M in FY14

Of the total $44.2M generated, $16.9M of the savings was shared with Trinity Health ACOs

Our initial ACO investments have yielded positive shared savings

Investment in ACOs

Total Savings Generated

$16.5M

$27.3MPayer Share

$16.9MACO Share

$44.2M


IT infrastructure and data-driven claims analysis

Combining internal claims data platform and analytic resources with

industry-recognized tools to report provider performance across the enterprise to provider

levels

Standardized care management

process across the continuum

Maximize efficiency in post-

acute and SNF care

Reduce unnecessary or avoidable

hospitalizations

New operating capabilities improve care and lower cost for patients in ACOs

Targeting high risk patients through

predictive modeling and coordinating patient

care through multidisciplinary teams

at the site of care

Identifying clinicians to focus on SNF population

and collaboratively manage transitions

alongside BPCI teams, utilizing home care

partnerships

Improving access to primary and specialty

care providers, engaging hospitalists in adhering

to transitions of care processes




Together




initiatives







Individuals

Community Engagement:

Clinical Services:


Efficient & Effective Care Delivery through Trinity’s

Safety Net System

Triple AimBetter health Better care Lower costs

Efficient & Effective Wrap Around Services Focusing on the Vulnerable & the

Poor

Community Transformation:

Community Building Focusing on Built-Environment Economic

Revitalization, Housing, & other Social Determinants of Health

Innovation in Care Delivery

Innovation in Technology

Innovation in Financing

Transforming, Healing Presence in the Communities We Serve



Clinical Services:



Safety Net System



Poor









Dual eligible beneficiaries are among the poorest and sickest beneficiaries covered by either program.

Most have multiple chronic conditions.

Nearly half have significant mental illnesses.

In 2013, over 10.7 million individuals were dually eligible for Medicare and Medicaid benefits.

Transforming Safety Net Care with a Focus on the Duals


©2014 Trinity Health. All Rights Reserved. 28Innovation Council - Internal ©2015 Trinity Health - Livonia, MI

Nationally, Duals accounted for a total of $284.5B in spending in FY ’10. Today, spending is estimated to exceed $300B.

Spending on the “Duals” accounts for approximately 2% of GDP.

Trinity Health provides care to more than 207k Dual-eligible patients, representing $1.5 Billion in acute care revenue, annually.


Spending on Dual-eligible Patients is High

Innovation Program – Internal @2016 Trinity Health – Livonia, MI 28


http://trinityhealthchallenges.org

May 2, 2016 Challenge launch

June 10, 2016 Letter of Inquiry (LOI) deadline

July 15, 2016 Notify if invited to complete an application

August 19, 2016 Application deadline

September 26, 2016 Innovation Council meeting/ virtual showcase

October 15, 2016 Announce awards!

3030

Challenge Timeline

©2016 Trinity Health - Livonia, Mich.


Clinical Services:



Safety Net System



Poor










What Drives Good Health Outcomes? Access and Quality of Care ≈ 20%

Self-Referral or by Family

or Friend

Homeless Shelter

Community Transport Services

Independent Physicians

Our Desired Future:Better Health, Better Care, Lower Cost

33

Inpatient Acute Care

Continuing Care

EDEmployed & Independent Physicians

HUBCHWs &

Data

Medication Assistance

Insurance Enrollment

Pregnancy Assistance

Social Services

Care Management

Programs

(e.g., Faith Nursing;

Complex Care)

Integrated Delivery

Network

NOTE: Examples of

HUB services. Many

others are sponsored by

the community/RHM.

Nature of our Ministry:

Community at Large (501r)

Behavioral Health

Social Determinants

(e.g., Race/Ethnicity,

Gender, Income Level,

Language, Literacy, Living

Location)

Data DataACO

Sample

Referral

Sources



We Can Make a Real Difference in Patients’ Lives

Muskegon Health Project

Pathways to a Healthy Pregnancy

Muskegon, MI

Katrena H.

Patient

Ka’Ziya H.

Baby&

Pre-Community

Health Worker

Involvement

• Homeless

• High-risk

pregnancy

• Needing

prenatal care

Post-Community

Health Worker

Involvement

• Has housing and

resources for new home

• Received prenatal care

• Delivered a healthy baby

Before we met you, we were

homeless and we were going

from place to place.- Katrena H.

Deployment of 50 Community Health Coordinators

Part of a 2015 AmeriCorps Partnership

Challenge Grant

Community Health

Workers

Up to 10 CHWs

deployed in each targeted

MSSP and BPCI program

Focus on the Duals

Advanced analytics to

identify highest-risk

patients

Deploy CHWs & HUB / Pathways

Model to address social needs

Community Engagement


Measuring ImpactExisting MSSP ACO metrics / dashboards

will be used to evaluate the impact of

deploying up to 10 CHW at each of the 6

targeted ACOs.



Clinical Services:



Safety Net System



Poor









Health Does Not Begin In A Doctors Office…

Access to healthy and affordable food

Built-environment

Race / Ethnicity

Economic opportunity

Educational opportunity

Root Causes of Good vs. Poor Health

Safe places for kids to learn and play

Food and beverage environment in schools

Socioeconomic status / Income

Other social determinants of health

Clinical care(just the tip of the iceberg)



Anticipated investment of $80 million over 5 years in community health interventions.

Funding local partners with Several national partners at the table.

Applications are led by Community Coalitions, Local public health agencies & Trinity Health Ministries

$17.5 M

Transforming Communities Funding OpportunityLaunched in Nov 2015

• Boise, ID (Promise Partnership)

• Maywood, IL (Proviso Partners for Health)

• Silver Spring, MD (Healthy Montgomery)

• Springfield, MA (Live Well Springfield TCI Partnership)

• Syracuse, NY (Syracuse Health Coalition)

• Trenton, NJ (Trenton Health Team)


Six Communities Selected to Be Funded:

• Implementation of Tobacco 21 policy

• Development/ implementation of Complete Streets Policies

• Implementation of Nutrition Standards in Head-start & Daycare

• Enhancement of Breastfeeding Policies

• Expanding Physical Activity School Board Policies

• Implementing Food and Beverage Standards/Policies in Schools


Select Strategies to be Implemented Across all Six Communities


Tobacco policy work is integral to our Community Health and Well-Being strategy.

The longevity gaps in America are growing, not shrinking.

CDC researchers have concluded disparities in tobacco use account for 20% to one-third of growing life expectancy gaps.

Living in locations that have not adopted strong tobacco control measures is directly correlated with growing health disparities and longevity gaps.

Our commitment to vulnerable populations, especially people who are poor, demands action.


Our Tobacco Policy Focus

• Pass and/or Strengthen Clean Indoor Air Laws

• Tobacco Free Campus Policies

• Tobacco 21: Raising the Legal Purchase Age to 21

Community Transformation

©2016 Trinity Health - Livonia, MI

44

of Americans live in states with strong state-level protections. Everyone else relies on local governments to close the gap, or must advocate for state-level changes.

53%

Source: Americans for Non-Smokers Rights.

6 States In Our Network Diversified Network

Loopholes for many workplaces and bars

Loopholes for bars

Loopholes for barsand restaurants

No state law!

states within our footprint have weak clean indoor air laws for combustible cigarettes6

Strong state law

A Patch-Work Quilt of SmokeFree Laws Leave Many Behind

Institute of Medicine

Tobacco 21 Will Reduce Smoking and Save Lives

©2015 Trinity Health - Livonia, MI46

decline in smoking

initiation by 15-17

year olds

25% overall drop

in smoking

prevalence

12% reduction of

smoking related

deaths

10%

For kids alive today, 4.2 million years of life would be

saved by virtue of this logical, simple policy change.

Other Important Impacts…

Decline in

premature births12%Drop in

SIDS cases16%©2015 Trinity Health - Livonia, MI

Tobacco 21: Over time…


In 2016, alone, we’ve experienced big wins in many of the communities we serve.

• January 11: New Jersey passed Tobacco 21 law (pocket veto)

• March 16: Chicago passes Tobacco 21 and other historic measures

• March 29: South Bend passes state’s strongest smoking ban

• April 12: Washington, D.C. Congressional briefing likely to result in several additional co-sponsors on Federal legislation

• April 26: Albany County passed Tobacco 21 (bill not yet signed)

• May 10: California Tobacco 21 and other historic bills signed into law

• May 18: Illinois Tobacco 21 passed out of the Senate

Building a “People-Centered Health System” together




initiatives

Serving those who are poor, other populations, and impacting the social determinants of health





Individuals


Discussion…

@choucair

#PPBmeeting

The Paradigm Shift from Healthcare to Population Health

Healthcare

Transcript of The Paradigm Shift from Healthcare to Population Health