The Intensive Medical Home

An Overview of Value Based Care:
Is it all about the Data?
WEDI Healthcare Innovations Summit
Bill Patten
DVP, Value Based Care Programs
Blue Cross and Blue Shield of Illinois
March 26, 2014
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Agenda
• Is it all about the Data?
• Value Based Care: some basic principles
• ACOs and Medical Homes in the Blues’ Network
• The Value Proposition for Data in Value Based Care
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4 Defining Trends in the Health Care System
• The core function of Health Care Providers is shifting
from acute care to chronic disease management
• New information & communications technologies are
transforming business models and production processes
• A cost-trend reduction in health care spending will
restructure the provider-patient relationship
•As unit price increases go down or flat line Providers will
look to outcome bonuses to supplement their revenue
3
Factors impacting cost of care
4
HC Management Strategy
Vision: Increase the value of health care services by transforming care delivery
Markets
Individual / Exchange
Medical
Management
Programs
Value-Based
Care Models
Fully Insured
(Group)
ASO
Pharmacy
Medicaid / Medicare
Infrastructure Capabilities
Health Information
Technology
Use of Data
Communications
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5
Provider Segmentation
IPA
Individual
Physician
Integrated Delivery System
Small /
Medium
Physician
Practice
Large Multi-
Specialty
Practice
Hospital /
Health
System
Affiliation
Ex. Advocate
Hospital /
Health
System
Employed
Ex. OSF,
PHO
TRENDING
Strategic questions we’ve considered:
1) Do we accelerate the trend with risk based agreements?
2) Can we slow the acceleration of the trend?
3) How do we ensure our relevance and success?
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Value Creation in Sharing Risk &
Aligning Incentives
Benefit
Design
Care
Management
Payment
Model
2013 BCBSIL
Membership: 2.5 MILLION
Fee-forService
3K
Pay for
Performance
Medical
Home
240K
Accountable
Care
Organization
(ACO)
545K
200K
Shared Risk
HMO
Global
Payment
or % of
Premium
Population Health
HCSC Medical
Management
Overlapping Medical
Management
PPO Benefits
Delegated Medical
Management
HMO Benefits
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Blue Plan Care Delivery Innovations
Care delivery innovations are in market or in development in 49 states, District of Columbia and
Puerto Rico
Care Delivery Innovations
Pay-for-Performance Programs
Patient-Centered Medical Homes
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Note: Information as of January 22, 2013.
Episode-Based Payment
Accountable Care Organizations
New Models: Intensive Medical Home
Physician-employed Case Manager for Highest-Risk Patients
Top 10% of patients drive ≥65% of costs: How can we control costs
without better managing these patients?




Multiple chronic diseases
Poor lifestyle choices (weight,
smoking, no activity)
Incompletely treated depression,
anxiety, substance abuse


RN employed in practice; dedicated to highrisk cohort: 1:200
Offers medical and psychosocial support
Coordinated, Accountable, and PatientCentered Care
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The Intensive Medical Home
Metrics and Evaluation (for first nineteen (19) months thru 11/30/2013)
•
Interim Experience (19 months): 5/1/2012 thru 11/30/2013
• Total enrollment thru 11/30/2013:
2,963
• Current Acceptance Rate (% of targeted members enrolled):
70.5%
•
Care Plan written and agreed to by all enrolled members:
100%
•
Depression screenings and medication reconciliations:
100%
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ACO SHARED SAVINGS
WHO
•
•
•
•
HOW
10 hospitals and 4,000 physicians
200,000 attributed Blue Cross PPO lives
120,000 Blue Cross HMO lives
$2 billion annual Blue Cross spend
WHAT
IF medical cost trend better than
network AND meet patient
quality, safety, and satisfaction
metrics, THEN share in savings
WHERE
• Four-year (2011–2014) shared
savings PPO agreement with upside
and downside risk
• Four-year global risk HMO agreement
Metro Chicago, IL
(9 hospitals)
Bloomington, IL
(1 hospital)
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Advocate-BCBSIL Commercial ACO
(2 year results: 2011-2012)
• Largest Commercial ACO agreement in the
country
• 10.6% reduction in ER hospital admissions
• Total cost of care was 2% lower than aggregate
PPO
• Hospital admissions/1000 dropped 12.1%
• Inpatient days/1000 dropped 13.8%
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Attribution challenges
• Attribution of patients is a concern of providers in
payment reform models.
• Physicians contend that if their performance is to be
evaluated fairly, they should have control over the
patients or episodes of care assigned to them.
• Attribution can be made to individual physicians, or
to groups of physicians and other clinicians.
• Broader assignment may foster care team
collaboration.
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Key Findings from Bipartisan Policy Center
Health Information Technology Initiative
• A majority of clinicians believe that EHI
will have a positive impact on health care
• About 70% of clinicians surveyed believe
that the lack of interoperability and
exchange infrastructure, and the cost
associated with both, are major barriers
to electronic information sharing
• Timeliness of information is important
Bipartisan Policy Center Health Information Technology Initiative, October 2012, “Clinician Perspectives on Electronic Health
Information Sharing for Transitions of Care”
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Key Findings continued: “Skinny vs. Big Data”
• More than half of the respondents want
information they view as “essential” to get
“pushed” to them, with the ability to access
the rest of the information through a query
• Access to medication lists and relevant
laboratory and imaging test results are high
priorities for transitions of care
• Ability to selectively pick and choose what gets
integrated from an external source into an
EHR/EMR
Bipartisan Policy Center Health Information Technology Initiative, October 2012, “Clinician Perspectives on Electronic Health
Information Sharing for Transitions of Care”
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When It Comes to Data and Tools,
What do Value Based Care Providers Want?
•
•
•
•
•
•
Risk Stratify their patients: Population Health
Data in real time
Clean Attribution and claims data
Data or data plus analysis and analytic tools?
Care management tools at the pcp office level
Shared approach to incentives: Culture and
Tools
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Shared-Purpose Approach to Incentives
“An institution whose tradition, culture and mission health care
professionals can identify with; a climate of respectful social
interactions, which allows physicians to uphold their sense of
moral responsibility; institutional transparency; and a pro-active
attitude toward monitoring incentives’ effects on the quality and
fairness of patient care…that promotes the development of a
shared-purpose approach to incentives.”
NEJM, March 2013
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Questions??
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