Success Stories: Purchasers and the Health Care Home

1. Success Stories:Purchasers and the Health Care Home • Rushika Fernandopulle, MD. MPP • June 2012

2. An “Up at Night” Problem Increases 1999-2009 • Payers are getting poor value for health care spending, with suboptimal experience and outcomes, high and rising costs • Widespread consensus that the solution must go beyond bandaids and involve real changes in how care is delivered Kaiser Family Foundation and Health Research and Educational Trust. Employer Health Benefits 2009 Annual Survey. September 2009.

3. Primary Care is Key But Traditional Practices Not Up to the Task • Poor access- for appointments and in office • Lack of continuity • Force all interactions into visit • Episodic and not continuous care • Purely reactive, not proactive • Lack of information systems and decision support • Decisions made with poor, fragmentary data • Provide levels of customer service far below almost any other industry • Processes and outcomes (and prices) opaque to customer

4. Redesigning CareNeed all three legs of the stool Reward (or don’t disincent) quality and savings De-link payment from visits Increase investment in primary care Payment Data/IT People/Process IT and analytics to decide who to intervene on, engage patients, and manage the system Concept of Managing population Team based care- health coaches, huddle Culture of Service

5. The Imperative for Purchasers to Act Boldly • The poor value for health care spending is a strategic issue; manage it like part of the supply chain • Incremental efforts to impact the system have not worked- tweaking benefit design and incremental changes havent worked • No one else really is equipped to drive real change • As in every other industry it is the customer (the person who writes the checks) who can best trigger change • Real role for purchasers to catalyze real delivery system change by engaging directly with providers to change payment and delivery

6. The Boeing Intensive Outpatient Care Program • Self insured, over $2b/yr in health costs; major global competitiveness issue • 150K lives in Puget sound area • Work with 3 major medical groups to install better system for sickest patients • Sites paid case rate on top of existing FFS; no patient incentives • Care manager RNs placed into existing practices • Docs and RNs given list of highest predicted cost patients, reports on those out of control • Made shared care plans, allowed email and preferential visit access, ran some groups, proactively checked up on people with registries

7. “Wrap Around” Model Works, but Challenging • Only has worked with practices who are already high performing • Lots of pressure to return to business as usual • Range of engagement among docs and staff • Reality of multiple payers means that you need to run a hybrid model

8. AtlantiCare, a 2 hospital, not for profit health system partnered with us and a self insured payer (ocat 54 Fund) to build the Special Care Center (SCC), was launched July 2007. • This new practice, built from scratch based on the Iora model, resulted in dramatic improvements in experience and outcomes, elimination of racial disparities, and lower total spending • Atlanticare got much local and national attention from this innovation (including Baldridge award), learned a lot about care patterns, feels it helps raise the bar with other docs • Now has offered this to several other payers, including Horizon Blue Cross commercial and managed medicare, and several commercial plans; • Opened 1 more location, soon to open 2 more; starting to extend services to other docs What if you start completely from scratch?

9. Redesigned Process • Daily huddles with entire team • Teamlet model during the day (Bodenheimer) • Lots of non visit based care- email, text, video • Extensive use of groups- including Stanford Chronic Care Curriculum in 3 languages • Integrated Mental health, nutrition • Close feedback loops with pharmacy • Real time data for management, including daily hospital, ER feeds • Co-management with hospitalists • Proactive care- based on registry queries, event triggers

10. Improved Patient Experience

11. Dramatically Improved Outcomes

12. Total spending dropped a net of 12.3%; Driven mostly by large decreases in hospital admissions, ER visits, and outpatient procedures For all SCC patients enrolled in 2009, relative to control group created using propensity matching.

13. Working in Different Settings

14. Raising the Bar • We can build systems of care delivery that dramatically improve experience, outcomes, and affordability • Right answer is likely a combination of innovation and improvement • Purchasers have a key role in driving and guiding the changes that are needed “Insanity is doing the same thing over and over and expecting different results” -Albert Einstein