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Randall D. Cebul, MD
Better Health Partnership: Approach, Accomplishments,
and Investments
Director, Center for Health Care Research & Policy CWRU at MetroHealth Medical Center
President and CEO, Better Health Partnership
betterhealthpartnership.org [email protected]
October 9, 2015
Better Health’s Vision and Mission
To Help Northeast Ohio Become a Healthier Place to Live and a Better Place to do Business
By creating a safe space for health care
competitors to collaborate
Common RHIC Themes • Multi-stakeholder • Improve care, outcomes,
and costs for [adults] with chronic conditions
• Focus on primary care • >50% saturation of “health care market”
• Support Region-wide QI • Publicly report results • TRIPLE AIM
RWJF’s Aligning Forces for Quality Regional Health Improvement Collaboratives (RHICs)
2007–2015
Special Features of Better Health’s Collaborative
• Led by providers • Partnerships with state govt, public health agencies and
academia in addition to employers and health plans • Prominent focus on safety net and reducing disparities • Electronic medical records used for all clinics’ quality
measurement, public reporting and improvement • Identifiable patient-level “social determinants” – race,
insurance status, language preference, income and educational attainment
Berwick’s Triple Aim
Be#er Care Be#er Health
Lower Costs
BETTER CARE and BETTER HEALTH Using Publicly Reported Data and
Shortening the Path to Improvement
6
What We Measure, Report and Work to Improve
Measurement - at the heart of everything we do…
• Care and Control of Diabetes (2007-), Heart Failure (2008-), and Hypertension (2009-)
• Depression Screening (2012-) • Patient Experience (2012-) • Disparities across the region
EMR-based Measures to Reduce Disparities and Improve Population Health
(2014: 170K patients)
• Insurance • Race • Hispanic Ethnicity • Language Preference • Sex • Geographic Location • Household Income* • Education* * from ACS/Census
• Body-Mass Index • Blood Pressure • Smoking Status • Depression Status
Reducing Disparities in northeast Ohio
Better Health’s 10 Safety Net Systems
• Asia Services in Action • Care Alliance Health Center • Free Medical Clinic of Cleveland • Lake County Free Clinic • Louis Stokes VA Medical Center • MetroHealth System • Neighborhood Family Practice • North Coast Health • NEON • St. Vincent Charity Medical Group
Safety Net Orgs (SNOs) vs. Others: Competing in a safe space, level playing field
Patients with Diabetes, 2014
Reducing Racial Disparities in Diabetes Care
13
Safety Net
Income Disparities and Pneumovax
Our Secret Sauce for Improvement
“Who are those guys? How did they do that?”
Butch Cassidy (Newman) and the Sundance Kid (Redford)
1969
A Sauce for Improvement, not a Silver Bullet
1. Find the bright spots in our data (“those guys”)
2. Interview key informants - write up what they did
3. Disseminate the process in a safe space (here)
4. Re-measure adopters to see if they improved too 5. If they have improved, we have another
(Evidence-based) Best Practice.
Ingredients and Steps
2011-12: Finding Best Practices for Good Blood Pressure Control
50
69
81 83 83 84 85 86 87 89 89 90
0 20 40 60 80 100
REGION
-‐6
0 0 0 1
6 7
9 11
13 14 14 14 14
16 -‐10 -‐5 0 5 10 15 20
REGION
Bright Spots for Good BP control: The best 10 were from one system
Bright Spots for improvement: The top 6 were from the same system
“What system is this? How did they do that?”
Kaiser Permanente (now HealthSpan)
Improving BP control (2012-14) using HealthSpan’s Best Practice in the safety
net
25% improvement!
Regionwide change
Gold Star PracMces -‐ CongratulaMons !
Improving Care and Health: What about Costs of Care?
Projects that use our community
as a Learning Laboratory
Cost of Care Projects/Analyses 1. The Better Health Experiment (2009-11) – have
the number and costs of “preventable” hospitalizations declined?
2. The Red Carpet Care program (2012-13) – did a health plan-supported “super-utilizer” project reduce pmpm costs?
3. MetroHealth Care Plus (2013) – did a “closed panel” Medicaid waiver program improve quality/save $$s?
4. “Primary Care Push” (2012--)– will an employer-supported PCMH program at Lake Health improve quality and reduce costs?
The “Better Health Experiment”
• Better primary care should reduce the rate of “ambulatory care sensitive hospitalizations”
• Our primary care providers care for ~70% of adults with chronic illnesses in Cuyahoga County.
• Using an all-payer hospitalizations dataset, we asked whether preventable hospitalizations declined more in Cuyahoga County than in 5 other large Ohio counties.
Reducing Preventable Hospitalizations 2009-11: Cuyahoga Co. vs Other Large Counties
Averted Hospitalizations Increased Each Year
AVERTED: 2,200 HOSPITALIZATIONS $15.4 MILLION IN COSTS
532 ($3.5M)
830 ($5.7M)
848 ($6.3M)
2,210 ($15.4M)
0
500
1,000
1,500
2,000
2,500
2009 2010 2011 Total
# of
Hos
pita
lizat
ions
Ave
rted
and
Cos
t Sav
ings
[C
uyah
oga
Cou
nty]
Academy Health, 2013
Red Carpet Care – Super-Utilizer Program
• The best approach to caring for “super-utilizers” is not known.
• With the support of health plans, BH designed a s-u program with embedded RN care coordinators, home visits, and personal phone access to the RN 24/7.
• Health plans paid for the RNs, pmpm, and agreed to a shared-savings program.
• We asked whether the Red Carpet Care program reduced costs.
Estimated Savings in Total Costs of Care, per person, per year ($)
(MEDICAL MUTUAL)
• Difference = $4,734.36 pppy (394.53 pmpm) • Across 67 RCC patients, one year savings were
$317,200.
The MetroHealth System
Red Carpet Care (RCC) Enrollees (n = 67)
Control Patients (n = 44)
REDUCTION, per person, per
year $ 5,098.56 $ 364.20
MetroHealth Care Plus (MHCP) – a Medicaid waiver program in 2013
• Anticipating Medicaid expansion while debate about its demise continued, Ohio received a waiver to test an expansion in Cuyahoga County starting February 4, 2013
• 28,295 uninsured poor patients enrolled, with a median enrollment period of 9 months
• We re-purposed Better Health’s data to determine whether quality increased at lower costs among the enrollees vs. the continuously uninsured.
Features of MetroHealth Care Plus • Waiver conditions
– Closed panel care, 3 unaffiliated safety nets
– Accept risk of exceeding CMS expenditure cap
– No co-pays
• Prepared safety net orgs – committed to disadvantaged pops,
QI, transparency – All practices recognized PCMH – Mature users of EHRs+HIE – All members of Better Health
Cost: 28.7% ($167.36 per member-month) below federal expenditure cap, or $41M across all enrollees.
13.2
8.4
2.8 0
2
4
6
8
10
12
14
Diabetes Care Diabetes Outcomes Hypertension Control
Impr
ovem
ent i
n M
H C
are
Plus
min
us
Impr
ovem
ent i
n U
nins
ured
(in
% p
oint
s)
Difference in Differences Estimates
MHCP Results after 9 months enrollment: better care, better outcomes, savings
(Percentage points favoring MHCP enrollees)
Employer-motivated PCMH and transparency
• Three large self-insured employers wanted the best care for their employees. – They agreed to jointly support embedded
care coordinators in exchange for clinics achieving national PCMH recognition and publicly reporting their results.
• Did this unique arrangement work?
October 10, 2014 – “Kick-off” 11 Lake practices had won national recognition
for PCMH; now reporting with Better Health
Cost of Care Projects/Analyses
1. The Better Health Experiment – reduced preventable hospitalizations and related costs.
2. The Red Carpet Care program – reduced TCOC among “super utilizers”.
3. MetroHealth Care Plus – improved quality of care and saved (CMS) $41M.
4. “Primary Care Push” – Lake Health providers recognized for patient-centered care; publicly reporting and using employers’ support for care coordination
Better Health’s Triple Aim Approaches and Results
1. Approaches: Using data to identify and disseminate best practices for important conditions
• “Positive deviants” celebrated, their work disseminated
2. Results: Widely recognized improvement: • Care for adults with chronic conditions • Disparities in care across multiple dimensions • Preventable hospitalizations
Better Health’s New Initiative Children’s Health and Health Care
“Just as the twig is bent the tree’s inclined.”
– Alexander Pope (1732) Epistles to Several Persons
Childhood Asthma
Asthma care and outcomes are on Ohio’s radar
HAVE YOU RECEIVED A REPORT LIKE THIS?
Childhood Obesity
39
Clinical Care - Not the Primary Determinant of Health
Clinical Care
Underlying Determinants of Health
Only 20%!
50%
Can EHRs Help with “Social Determinants”?
• We have documented patients cared for in EHR systems do better and improve faster
• This is Not true for obesity • Adult BMI levels have remained flat over Sme • All of our partners care, but none has solved the problem • How can EHRs help?
Value of EHRs in addressing “social determinants”
• EHRs can identify: • where patients live • whether they are obese, have asthma, etc • related conditions and risk factors • local resources to help
• EHRs also can: • catalyze place-based interventions
• e.g. REC centers, museums, parks, businesses, grocery stores, assessments of at-risk houuseholds…..
• help us monitor progress
Proximity of Municipal Rec Centers to our Patients
8,930 Metro adults with diabetes:
Cuyahoga County, Ohio 65% obese (BMI>30)
White Black
Hispanic Other
Our Overweight and Obese Children Can use nearby resources
30,425 – ages 2-18 4,869 - overweight (BMI 85-94 %ile) 5,870 – obese (BMI > 95 %ile) 35.2% - obese or overweight
Obese Overweight
Health Care Near Our Children’s Schools Can help us intervene early
Children’s Health and Health Care What Better Health has done to date
• Committed to the Initiative: Board of Directors, Leadership Team, Clinical Advisory Committee (CAC)
• Established CAC Children’s Sub-Committee • Consensus support for asthma and obesity
• Begun to recruit independent Pediatricians, Children’s Hospitals, and Pediatricians in large systems
• Embarked upon a multi-sector environmental scan of interest and ongoing activities
• Met twice with leaders of Institute of Medicine “CEO Innovation Collaborative” to support Cleveland
How Better Health will help
• Expand our established “backbone organization” activities in adult conditions to children: measurement, reporting, learning collaboratives, practice coaching (PCMH etc)
• Serve as convener across providers, public health agencies, state and local policymakers, and other stakeholders for children’s health
• Establish a Community Resource Database and website for use by providers and the public • Linking providers – through their EHRs - to resources near where
their patients live
www.betterhealthpartnership.org
How Can You Help?
