Behavioral Economics and Care Teams- A Winning Combination

1. Behavioral Economics and Care Teams-A Winning Combination Jerry Reeves MD wellPORTAL and HealthInsight

2. Objectives • Review impacts of choices and systems on healthcare outcomes and well-being • Review top plan sponsor priorities • Describe behavioral economics and care team interventions driving better health choices and outcomes • Call for action

3. Cost and Quality Drivers • System Factors • Normal inflation • Worker shortages • New technologies • New treatments • New drugs • New science • Higher US prices • Population aging • Choice Factors • Care pattern variations • Fragmented • Uncoordinated • Preference sensitive • Perverse financial incentives – volume • Lack of cost & quality transparency • Obesity epidemic From Healthcare Will Not Reform Itself: A User’s Guide to Refocusing and Reforming American Healthcare George Halvorson. CRC Press 2009

5. Who Needs to Drive Change? Sources of Payment for Health Care Services: • Employers: 55% • Self Pay: 10% • Medicare: 15% • Medicaid: 15% • Military: 5% From: Income, Poverty, and Health Insurance Coverage in the United States: 2010 U.S. Census Bureau, Sept 2011

6. Episode Treatment GroupsHow the Costs VaryUrinary Tract Infection – Internal Medicine $778 $140 $81 Doctor Choices - Why Not?

7. Episode Treatment GroupsHow the Costs VaryKnee Joint Derangement – Orthopedic Surgery $9,383 $4,473 $2,727 Doctor Choices - Why Not?

8. Emergency Department Choices From: Massachusetts Health Care Trend Report, August 2010 $1,000 Excess Cost Per Visit - (per CDC, 2013)

9. The Obesity Epidemic After a short stay in America, Michelangelo’s David returns to Florence

11. Poor Choices Hot Spots – Where Nudges Are Needed From: http://info.healthways.com/wbi2013

12. Plan Sponsor Priorities • Better health & well being at lower cost • Reduce cost shifting to employees • Reduce high cost outliers • So well that doctor visits are less needed • Engage members in better health choices • Choose well, live well – all year through • Leverage on site health centers • Engage contracted providers in better choices • Journey to shared risk and savings

14. Expected Results Quality Patient Satisfaction Costs

15. Behavioral Economics and Choices –Key Principles* • We are predictably irrational • System 1 (fast) impulses drive irrational decisions • Eat the brownie • System 2 deliberative reasoning (slow) drives rational decisions • Should I eat the brownie? • Nudges and choice structure favor System 2 • Who took my brownies? *From: Thinking, Fast and Slow- Daniel Kahneman; Why Nudge- Cass Sunstein

16. Applied Behavioral Economics -Driving Better Choices • Aligned Financial and Non-Financial Incentives • Strong and Frequent Rewards and Consequences • Accountability System- Knowing “they” know • Acting on Whether Promises Are Kept • Member Activation – Health Coaches & Doctors • Motivating Confidence, Ownership • Ample feedback on successes and achievements • Nudges- Making right choices easier

17. Choosing Better Care Delivery - • Immediate / Emergency Care • Walk In Care/ Telehealth • Retail Clinics/ Pharmacy • Near Site Clinic/Pharmacy • On Site Clinic/ Pharmacy • Mobile Van Clinic • Rented Networks • Medical Home Benefit Plan Necessary: Connectivity, Coordination, Continuity

18. Care TeamsSurround Sound • Patient • Family, (Power of Attorney), Friends • Attending Physician • Health Coach(es) • Nurse / Care Manager • Pharmacist • Social Services/ Patient Advocate • Behavioral Health • Other

19. Health Home Benefit Plan-Connected, Coordinated, Continuity Care Teams Patient

20. CONNECTED

21. wellPORTALPatient Registry -Coordinated

22. wellPORTAL Patient Compliance Process -Continuity

23. wellPORTAL Health Management Program-Making It Easy • Registered nurse disease managers and health coaches • Locally staffed and managed • Integrated with primary care delivery (PCP/Medical home) • Integrated with all wellPORTALsystems • Allows for appropriate resource allocation • Team leader approach • Face to face support • Telephonic support

24. Plan Sponsor Responsibilities • Commit to an Incentive-Driven Health Improvement Strategy – Behavioral Economics • Health Home Plan Design Option • Differential Contributions • Health Home vs Freedom of Choice Plan • Richer Coverage of High Value Services • Provide members access to high performing physicians and resources • Implement a system for monitoring adherence and communicating with members • Establish consequences for non-adherence

25. What is in it for the Plan Sponsor? Three fundamental improvements: • Cost • 10-15% reduction Yr. 1 in expected PMPM claim cost • Trend reduction in Yr. 2 and beyond • Quality • ≥ 85% documentation of health care quality measures with active follow through • Patient Satisfaction • ≥ 85% patient satisfaction

26. Patient Responsibilities – Shared Care Plan

27. What is in it for the Patient? • Eligible for enhanced benefits and/or preferred contributions • Enhanced PCP access and customer service guarantees • Dedicated phone line • Same day access • 60 minute max appointment times • Allow patients to schedule longer visits for care coordination • A PCP who knows the patient and how the health plan works

28. Provider Responsibilities

29. Provider Responsibilities

30. What is in it for the Provider? • Enhanced global payments for becoming a PCMH Provider • Bonus compensation for achieving pre-designated performance goals • PCP and health plan sponsor are partners • Innovative tools & resources to manage patient care • Publicity & recognition • Opportunity to practice ongoing team based primary care medicine

31. Client 1 Cost & Utilization Report • 2nd Program Yr (July 12-June 13) Standard Method * Net of claims above $300,000 Stop Loss ** Mature claims – 7 months run-out • Cost • Patient Satisfaction • Quality

32. Key Cost & Utilization Metrics

33. Client 1 SelectQuality Measure Results2012 HEDIS CONTROLLED • Quality • Cost • Patient Satisfaction

34. Patient Satisfaction Results • Cost • Quality • Patient Satisfaction • * Patient Survey Results are for 2 year measure Reeves J, Kapp B. (2013) Improved Cost, Health, and Satisfaction with a Health Home Benefit Plan for Self-Insured Employers and Small Physician Practices. J Ambulatory Care Manage 36(2):108-120

35. Behavioral Economics and Care TeamsA Winning Combination • Aligned Incentives • Coordinated Care Teams • Performance Transparency • Activation

36. Call to Action

37. Jerry Reeves MD Vice President, Medical Affairs HealthInsight Nevada Medical Director wellPORTAL C: 702 743 1964 E: jreeves@healthinsight.org jreeves@wellportal.com