From Volume to Value

New Direction in Delivering Care

Week 2
 Agenda
• Introduction: Policy Environment: Understanding the Context of PHM
• Triple Aims for Populations & Hospitals
• From Volume to Value: Progress & Evidence
• In Class Exercise
 Introduction
The US Health Care Delivery System…
• Is a massive and complex system…
• Has a few major subsystems…
• Technology driven and focusing on acute care…
• Network of providers…

• High on Costs, Unequal to Access, Average on Quality

 Some changes
• Advance use of technology…
• Managing illness to managing health...
• Integrated delivery systems…
• Pay for performance, bundled payment…

• Volume to Value…
 Policy Environment
• Prior the 2010 Affordable Care Act (ACA)
• PPACA of 2010
• Subsequent Impacts of the ACA
 Prior 2010 – HITECH Act
The Health Information Technology of Economic and Clinical Health (HITECH) Act,
initiated under Title XIII of the American Recovery and Reinvestment Act of 2009,
focuses on improving quality, safety & efficiency, patient engagement, coordination
of care, population health, and privacy & security by:
1. Requiring providers to make meaningful use of their EHR and financially rewarding
the initiatives
2. Requiring standards and certification of EHR
3. Strengthening the infrastructure: technical support, workforce, demonstration
projects, R & D centers
 PPACA of 2010
The Patient Protection and Affordable Care Act (PPACA) addresses population
health in four ways:
1. Expand coverage to a near-universal guarantee off access to affordable
health insurance coverage (life time)
2. Seek to improve health care value, quality and efficiency (accountable)
3. Strengthen access to primary health care, prevention, and health promotion
4. Promote investment to community and population health
 *Some changes…*
• Create premium and cost-sharing subsidies, new rules for health insurance industry, create new
market, mandates…
• Require “minimum essential coverage”, expand Medicaid eligibility & dependent coverage
• Require coverage of recommended prevention services & for creating personalized annual
Medicare wellness visit plan
• Experiment new modes and of payments and service delivery…
• National Prevention, Health Promotion, and Public Health Council – to develop a prevention
and health promotion strategy of the country
• Prevention and Public Health Fund – annual appropriation for prevention and wellness
 Subsequent Impacts
• Percentage Uninsured & Barriers to Care
• Numbers of ACOs & Industry Consolidation
• Quality: Reductions in HACs and Medicare Readmissions
• Costs: Slowdown in the rate of increase in national health care spending
• Disparities: Income-related gaps declined more in expansion states
 Triple Aims for Populations
The Institute of Healthcare Improvement (IHI) suggested the following to achieve the IHI Triple Aim
(improvements in health, experience of care, and reduction in costs):
• New models of population health management;
• Starting with high-risk, high-cost populations;
• Large campaigns and other population health initiatives to improve population outcomes at scale,
with a particular focus on reducing disparities or inequities;
• Extending reach and impact by building capacity and skills for population health improvement; and
• Providing assessment, design, and capability for comprehensive quality strategies for nations and
other large health systems.
 Achieving the Triple Aim
Preconditions for this include
• enrollment of an identified population – specifying a population of concern,
• a commitment to universality for its members – “inclusive” policy
• the existence of an organization (an “integrator”) that accepts responsibility
for all three aims for that population – that can induce coordinative behavior
among health service suppliers to work as a system for the defined
population.
 Achieving the Triple Aim
The integrator’s role includes at least five components:
1. partnership with individuals and families through transparency, systematic education,
communication, and shared decision making with patients and communities
2. redesign of primary care to enable practices build long term relations with their
“population”
3. population health management that facilitate efficient and equitable resource allocation
4. utilize value driven financial management
5. pursue population-based interventions that are evidence-based, highly reliable, cost-
conscious, and making progress
“The Holy Grail of universal coverage may remain out of reach
unless, through rational collective action overriding some
individual self-interest, we can reduce per capita costs.”
 Zeroing in on the Triple Aim
1. Improving the patient experience of care
1. Reducing the risks of HACs
2. Partnership for Patient campaigns
3. Increasing adherence to Evidence-based Practices
2. Improving the health of populations
1. Conducting community health assessment and community-based initiatives
2. Reductions in readmissions
3. Reducing per capita costs of health care
 From Volume to Value
• Objectives: Use of value-driven outcomes tool in reducing costs &
improve patient outcomes
• Setting: University of Utah Health Care (2012-2016) Clinical
Improvement Projects (total hip and knee joint replacement, hospitalist
laboratory utilization, and management of sepsis)
• Data: Cost variation, total and component inpatient and outpatient direct
costs across departments, care costs and composite quality indexes
 From Volume to Value
• Results: Implementation of the tool was associated with a significant
decrease in costs and improvement in quality
• Total Joint Replacement: average costs 7-11% lower & ↑ perfect care
criteria
• Hospitalist Lab Use: daily lab costs 11% lower and ↓ risk of 30-day
readmission
• Sepsis Value Improvement: reduced time from SIRS criteria to first anti-
infective agent administration
 In Class Exercise
• CareOregon
• Genesys Health System
• QuadMed
 Questions
• Integrators? (Macro) Oregon-based nonpro t managedhealth care plan serving Medicaidenrollees, including those duallyeligible for Medicare. (Micro) Safety-net
medical clinics operatedby a public health department, alocal hospital system, and federallyquali ed health centers and similarcommunity organizations
• Target Population? Low-income patients, including those with complex chronic conditions, who are served by safety net clinics
• Care Model? 1) Fostered the development of patient-centered medical homes in safety-net clinics (known as Primary Care Renewal)
• 2) Developed a multidisciplinary case management program
(known as CareSupport) to help high-risk members and community-based resources, resolve difficult behavioral issues, and improve self-management
• Early Results? • CareSupport yielded savings
of $5,000 per-member, per-year
for high-risk patients through
better coordination of care, whilemaintaining or slightly improvingtheir quality of life.
• Implementation of patient-centered medical homes insafety-net clinics was associatedwith improved continuity of care,health screenings, and chronic
care management (e.g., 7 percentincreases in the proportion ofpatients with controlled bloodpressure and of patients withcontrolled diabetes during oneyear).
• As a likely result of bothinterventions, median monthly costswere 9 percent lower for duallyeligible patients who received carein medical home pilot sites
versustraditional care sites.
• Triple Aim Outcome Measures?
 More Examples
• The Cincinnati Children’s Hospital Medical Center
• Advocate Health Care’s Christ Medical Center
• The Henry Ford Health System
• HealthPartners
• St. Catherine Hospital in Garden City, Kansas
• St. Joseph Hospital in Sonoma, California
 More Examples
• “Just for Us” – Duke University Health System
• “The Breathe Easy at Home” – Boston, Massachusetts
• “The Congregational Health Network” – Memphis
•