Accountable Care:

A Path Toward the Triple Aim?Trissa Torres, MD, MSPHSenior Vice PresidentInstitute for Healthcare Improvement

G8

April 11, 2014

Agenda

ACOs…

Why

What

Progress

Toward Success

International Comparison of Spending on Health, 1980–2010

Average spending on healthper capita ($US PPP)

Total health expenditures aspercent of GDP

Notes: PPP = purchasing power parity; GDP = gross domestic product.Source: Commonwealth Fund, based on OECD Health Data 2012.

Males Females

Rank Country Average Length of Life Rank Country Average Length of

Life

1 Switzerland 79.33 1 Japan 85.98

2 Australia 79.27 2 France 84.43

3 Japan 79.20 3 Switzerland 84.09

4 Sweden 78.92 3 Italy 84.09

5 Italy 78.82 5 Spain 84.03

6 Canada 78.35 6 Australia 83.78

7 Norway 78.25 7 Canada 82.95

8 Netherlands 78.01 7 Sweden 82.95

9 Spain 77.62 9 Austria 82.86

10 United Kingdom 77.43 9 Finland 82.86

11 France 77.41 11 Norway 82.68

12 Austria 77.33 12 Germany 82.44

13 Germany 77.11 13 Netherlands 82.31

14 Denmark 76.13 14 Portugal 82.19

15 Portugal 75.87 15 United Kingdom 81.68

16 Finland 75.86 16 United States 80.78

17 United States 75.64 17 Denmark 80.53

Wealthier, Not Healthier

Source: Institute of Medicine. U.S. Health in International Perspective: Shorter Lives, Poorer Health. Available at: http://www.iom.edu/Reports/2013/US-Health-in-International-Perspective-Shorter-Lives-Poorer-Health.aspx

Social Spending

Source: Bradley EH, Elkins, BR, Herrin J, Elbel B. “Health and social services expenditures: associations with health outcomes.” BMJ Quality & Safety. March, 2011. http://qualitysafety.bmj.com/content/early/2011/03/28/bmjqs.2010.048363.abstract

An all too familiar scenarioIt’s scary when I can’t breathe.

Sometimes I’m just too tired to go to the doctor.

I miss my family.

An all too familiar reactionI know what she needs, but not how to help her.

If only someone could check on her.

I don’t have the time or the resources.

Affordable Care Act (ACA) “Obamacare” Increasing Coverage, Changing Care Models

2010 2011 2012 2013

President Obama signs the Affordable Care Act. (3/23/2010)

Prohibit Denying Coverage of Children Based on Pre-Existing Conditions (9/23/2010)

Provide Free Preventative Care(9/23/2010)

Bring Down Health Care Premiums (1/1/11)

Increase Access to Services at Home and in the Community (10/1/1/11)

Encouraging Integrated Health Systems &Launch of ACO Pioneer Program(1/1/12)

2014

Understanding and Fighting Health Disparities (3/1/12)

Improving Preventative Health Coverage & Launch of SSP ACO model (1/1/13)

Open Enrollment in the Health Insurance Marketplace Begins (10/1/13)

Prohibiting Discrimination Due to Pre-Existing Conditions or Gender (1/1/14)

Establishing the Health Insurance Marketplace (2014)

Source: U.S. Department of Health and Human Services

Accountable Care Organization (ACO)

Definition

An ACO is an organization of health care providers that agrees to be accountable for the overall care and cost of care for assigned beneficiaries

Experience of Care

Per Capita Cost

Health of a Population

Social circumstances

15%

Environmental exposure

5%

Health care10%

Behavioral patterns

40%

Genetic predisposition

30%

Determinants of Health and Their Contribution to Premature Death

Adapted from: McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff(Millwood) 2002;21(2):78-93.

Proportional Contribution to Premature Death

Triple Aim = Managing Populations

Triple Aim

Results

Defined Populations

Community-Wide

Populations

ACOs are a Payment Mechanism

Fee for Service

Pay for Performance

Shared Savings Shared Risk Global

Payment

Accountable Care Organizations (ACOs)

Source: Leavitt Partners Center for Accountable Care Intelligence

Now over 600 ACOs across the country

ACO Growth

Source: Leavitt Partners Center for Accountable Care Intelligence

ACO Growth by Organization16

Source: Leavitt Partners Center for Accountable Care Intelligence

Growth in Covered Lives

Source: Leavitt Partners Center for Accountable Care Intelligence

Serving over 18 million people

Preliminary ResultsGovernment Sponsored ACOs

Pioneer (n=32) SSPs (n=114)0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CMS ACO Financial Results Year 1

Shared Savings Savings Not At Target Did Not Achieve Savings

Source: The Commonwealth Fund and U.S Department of Health and Human Services

CMS ACO Quality Metrics

Patient/caregiver experience7 measures Timely, communication, specialist access, health promotion, shared decision making, perceived health status

Care coordination & patient safety6 measuresReadmissions, ASC Admissions for CHF, EMR, Med Rec, Fall Risk

Preventive health8 measuresInfluenza Immun, Pneumococcal, Wt screening, Tobacco assessment & intervention, Depression Screen, CRC Screen, Mamm Screen, BP assess

At-risk populations12 measuresComposite scores for management of Diabetes, Hypertension, Ischemic Vascular Disease, Heart Failure, Coronary Artery Disease

What might success look like?

EMS implements shared protocol to treat instead of

transport if appropriate

Care manager

checks on her regularly

Her son gets her a tablet and sets up Facetime

Physician’s office staff ask church members to visit

Population Management

Identify high-risk/high-cost patients using a variety of methods

Understand cost drivers within segments

Assess patient resources and capabilities and their socially-determined risk factors

Understand patient goals and preferences

Understand system barriers from patient perspective

Co-create holistic approaches that impact peoples’ health

Identify patient “archetypes” and design care platforms that encompass multi-sector partners

Move care as close to the patient as possible

Involve non-traditional health care workforce

ASSESS AND SEGMENT THE POPULATION

ENGAGE AND ACTIVATE THE POPULATION

CARE FOR THE POPULATION

ESTABLISH a CROSS-COMMUNITY SYSTEM of CARE: Invest (develop payment mechanisms) in social determinants of health

Build coalitions including patients and families to identify and advocate for policies that support the needs of this population Use stories and narrative to build will

Delivery of Services at

Scale

Community, Family and Individual Resources

Managing Services for a Population

FeedbackLoops

Needs Assessment for

SegmentService Design

CoordinationGoals

Integrator

Population Segmentation

Population Outcomes

FeedbackLoops

Activities of a Population Management Learning System

Click icon to add picture

Enabling and Constraining Factors

Leadership

Integrated Data Systems

Improvement Infrastructure (Learning System)

Provider and Stakeholder Engagement

Leveraging Financial Models

New Mental ModelsHow Leaders Think About Challenges and Solutions

Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. Cambridge, MA: Institute for Healthcare Improvement; 2013. Available on www.ihi.org.

High-Impact Leadership BehaviorsWhat Leaders Do to Make a Difference

Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. Cambridge, MA: Institute for Healthcare Improvement; 2013. Available on www.ihi.org.

Swensen S, Pugh M, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. Cambridge, MA: Institute for Healthcare Improvement; 2013. Available on www.ihi.org.

IHI High-Impact Leadership FrameworkWhere Leaders Focus Efforts

Population Management Assessment

Experience of Care

Per Capita Cost

Health of a Population

Improved provider experienceI am thrilled we are helping Mrs. Jones.

My team has come together.

Her family, church, and community have all come together to help too.

An all too familiar scenario

I’m not afraid.

Dr. Patel’s team helps me.

I don’t feel lonely anymore.

Recommendations to Accelerate the Journey…

“Act for the individual and learn for the population”

Understand what it truly takes to improve care for individuals

Leverage the richness of individual organizational learning

Create learning systems that enable ACOs to share with and learn from one another

Create more opportunities to convene representatives from the provider, payor, and health information technology communities