SOC 2013 - Jim Hester - National Interoperability Community of ...

Integrating PopulationHealth into DeliverySystem ReformStewards of ChangeJim HesterBaltimoreJune 10, 2013

I. ContextWhy Delivery System Reform?‣ Goal: Universal access to affordable, qualityhealth care for all‣ Issue: performance of existing system results inunsustainable costs‣ Approach: transformation of the current system toachieve and reward Triple Aims outcomes• Better health for populations• Better health care for those who need it• Lower total costs through improvement‣ Conceptual Model: Halfon, Healthcare 3.0

US Health Care Delivery System EvolutionHealth Delivery System Transformation Critical PathAcute Care System 1.0Coordinated SeamlessHealthcare System 2.0Community IntegratedHealthcare System 3.0Episodic Non-Integrated CareOutcomeAccountable CareCommunityIntegratedHealthcare• Episodic Health Care• Lack integrated care networks• Lack quality & cost performancetransparency• Poorly Coordinate Chronic CareManagement• Patient/Person Centered• Transparent Cost and Quality Performance• Accountable Provider Networks DesignedAround the patient• Shared Financial Risk• HIT integrated• Focus on care managementand preventive care● Healthy Population Centered● Population Health Focused Strategies● Integrated networks linked to communityresources capable of addressing psychosocial/economic needs● Population based reimbursement● Learning Organization: capable of rapiddeployment of best practices● Community Health Integrated● E-health and telehealth capable

II. Innovation in Payment Reform‣ Federal: CMS Innovation Center (CMMI)‣ State: Vermont Delivery System Reform

2011 Vision: CMS as a CatalystThe CMS MissionCMS is a constructive force and a trustworthypartner for the continual improvement ofhealth and health care for all Americans.7

The Innovation CenterACA Charge (S 3021): Identify, Test, Evaluate, Scale“The purpose of the Center is to test innovative paymentand service delivery models to reduce programexpenditures under Medicare, Medicaid, andCHIP…while preserving or enhancing the quality of carefurnished.”• Resources: $10 billion funding for FY2011 through 2019• Opportunity to “scale up”: The HHS Secretary has theauthority to expand successful models to the national level8

Delivery TransformationDelivery Transformation ContinuumContinuumPartnershipfor PatientsInnovationChallengeComprehensivePrimary CareBundled PaymentACOs-Advance PaymentPioneerACOsProviders can choose from a range of caredelivery transformations and escalatingamounts of risk, while benefitting fromsupports and resources designed to spreadbest practices and improve care.Tools to Empower Learning and Redesign:Data Sharing, Learning Networks, RECs, PCORI, Aligned Quality StandardsPatient-CenteredSystem ofthe Future

Measures of SuccessBetter health care:Better health:Lower costs throughImprovement:Improving patients’ experience of care within the Instituteof Medicine’s 6 domains of quality: Safety, Effectiveness,Patient-Centeredness, Timeliness, Efficiency, and Equity.Keeping patients well so they can do what they want todo. Increasing the overall health of populations: addressbehavioral risk factors; focus on preventive care.Lowering the total cost of care while improving quality,resulting in reduced expenditures for Medicare, Medicaid,and CHIP beneficiaries.10

Population Health at CMMICreate the Vision: Articulate a clear conceptual framework for evolution ofhealth system built on national strategies for quality and prevention1. Measure• Develop robust set of measures for tracking changes in population health2. Test New Models of Payment and Service• Strengthen population health focus in all models• Identify and support innovations which integrate clinical care with community based focuson determinants of health3. Build Collaborations• State• Private payers• Federal Partners (e.g., CDC, AoA, HRSA, DOD)• Public health: e.g. ASTHO, NACCHO• Public/private coalitions4. Promote and Teach• Catalyst , exemplary case studies, IAP,11

Health Care Innovation Awards:Population HealthPopulation Health Portfolio• 21 awards for a total of $114 million• 12 awards managed by CDC program officers: team of program officers, subjectmatter experts and leadershipExamples of Themes of interventions• Diabetes cluster, eg multi-state large scale test of YMCA Diabetes PreventionProgram• Community based asthma prevention and care cluster, eg Nemours test inDelaware• Community based determinants of health ,eg MI Public Health Institutecommunity pathways, Chicago Community Rx• School healthRound 2 in process

VT Health Reform600,000 total populationGoal: improve the health ofVermonters13 Hospital Service Areasdefine ‘community systems’Payers: 3 commercial + 2publicLaboratory for healthreform13

III. Delivery System Reform andPopulation Health‣ Status‣ New population health financing models• Opportunities• Threats

Status: Growing Opportunity‣ Broad diffusion of language supporting betterhealth for populations,‣ New payment models being tested at scale‣ New options: Hospital community benefit,bank community reinvestment‣ Signs of initial regional markets aligning , egComprehensive Primary Care Initiative,‣ BUT, Delivery system evolution lags rhetoric,with broad distribution across Halfon’s scale• Laggards stuck in 1.0: It still works financially• Many working to achieve 2.0 at practice andcommunity levels• A very few exploring path to 3.0

Challenges for PopulationHealth Financial Models‣ Other dimensions of value (total cost, patientexperience) have a long history of being used inpayment models• Interventions better understood• Measures and instruments developed• Accountability more clear cut‣ Tasks associated with managing total cost andpatient experience are all consuming‣ Population health business case requiresreinvestment of shared savings from multiplesectors and valuing long term impacts 19

ChallengesImproving population health is intimidatinggoal• Determinants of health model not readilyunderstood: Tendency to focus on thefamiliar, clinical services that health providerscontrol directly.• Portfolio of validated interventions for key riskfactors eg obesity, is small• Measures are poor: Confusion betweenquality of care and population health, focus onclinical measures 20

ThreatPayment models for population health in early stageof development‣ Population health traditionally funded by grants,taxes, not payment for services‣ Infrastructure and tools for population healthimprovement are not well developed• Integrated service models for clinical care, publichealth and community based resources• Business case for payment models fundamentallydiifferent from impact on risk factors: CMS vs CDC• Robust measures for learning, accountability andpayment‣ Risk: new payment models will be established withno meaningful population health component

Theme: Recap‣ Health care system is transitioning from paymentbased on volume to value‣ Defining value based on Triple Aims outcomes couldcreate funding stream to reward improvements inpopulation health‣ The determinants of health imply integration of clinicalcare, public health and community services targetedon upstream determinants i.e., interoperability‣ A window of opportunity exists for population health toshift to more sustainable funding models‣ However, the complexity and relative weakness of keybuilding blocks required for payment models createsthe threat that population health will not beincorporated in new payment models in a meaningfulway