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Breakthrough Towards Better Health: A “Triple Aim” case in German region

Helmut Hildebrandt,

CEO OptiMedis AG & Gesundes Kinzigtal GmbH, CFO International Foundation for Integrated Care

h.hildebrandt@optimedis.de

Regiobijeenkomst Vitaal Vechtdal, Hardenberg, NL

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Health science put into practice: realizing Triple Aim

Cooperation Contract / Regional Health Management Company

Cooperation – in development:

Hamburg Billstedt-Horn Bielefeld Berlin/Brandenburg Mannheim Greifswald Bayern Leipzig

Switzerland

Austria

Helmut Hildebrandt Pharmacist, studies in sociology, over 30 years management and consulting experience for WHO and ministerial boards, hospitals, physician networks and others

CEO of OptiMedis AG

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Population Health in the Times of Global Financial Crisis: The Problem

Ageing societies with growing chronic care needs and complex societal risks and challenges

Scarcity of public funding & money

The health care system is still not oriented (and not rewarded) towards health/public health (health outcomes achieved) but towards care & cure (health care services provided)

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Aging population with growing chronic illness in NL: more but unhealthy years

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10

20

30

40

50

60

70

80

90

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’91 ’89 ’87 ’85 ’83 ’81 ’11 ’09 ’07 ’05 ’03 ’01 ’99 ’97 ’95 ’93

Year of birth

Without chronic disease

Life expectancy

Expe

ctan

cy (y

ears

)

Life expectancy (without chronic disease) Netherlands

Noot: onder chronische ziektes zijn begrepen Astma/chronische bronchitis, Hartafwijking, Beroerte, Hoge bloeddruk, Maag-darm stoornissen, Suikerziekte, Rugaandoening, Reumatische/gewrichtsaandoeningen, Migraine en Kanker Bron: CBS

Unhealthy years

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Scarcity of public funding: healthcare ‘share of wallet’ is increasing in NL

Budget 2014: € 77,8 billion >20% of government spending of €267 bln 13% of GDP, 15% incl all payments 23% of a middle class household income

New system Old system

Healthcare cost as share of government spending

Hoogervorst VVD

2003-2007

Klink CDA 2007 - 2010

Schippers VVD 2010 - now

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Integration of care delivery and financing around the patient is needed

to make significant improvements in care, health and thus costs: triple aim!

• Diabetes

• Cardio vascular

• COPD/Asthma

• Emergency care

• Dementia

• Bones/joints

• Loneliness

• Depression

• HCI basic

• HCI extra

• LTC

• Municipality

• Subsidy

• Own payment

• ...?

• GP

• Homecare

• Relatives

• Specialists

• iHealth

• Psychologist

• Pharmacist

• Paramedics

Healthcare system not oriented towards health outcomes, but cure and care inputs

Linda

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Population Health in the Times of Global Financial Crisis: The Question

? How to get a sustainable interest in investments in health and in delivering the best results?

? How to get local health care providers motivated for health/public health ?

? …. and how do we get this installed in a multi payer and multi provider system

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a. Law allowing health gains to be contracted and paid out

b. Contract innovation rewarding and sharing health gains

c. Regional ‘integrator’ organisation/cooperation/leadership

d. Triple Aim approaches: back to the real heart of medicine

e. Population data, data, data…..

National conditions

Local implementation

Making Population Health happen today: the solution

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Gesundes Kinzigtal (GK): Population Health & Integrated Care Network Management

Legal facilitation: Integrated care art. 140 in new law year 2000

Start and duration contract: 2006-2015, now indefinitely with AOK & SVLFG

Shared savings Insurers/GK: 1:2

On total costs of care (2013)*: 73 Mio. €

Population insurers: ~33.000, 46%

Total GK participants: ~ 9.750

Ø-age pop. / participants 45,7 / 61,6

Integrator organization

Reg. cooperation partners: ~ 160

Number of programs: ~ 20

Population data: all claims data anonymous from insurers

* AOK + SVLFG, without dentistry

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Lovely region – lovely people traditional and international minded with many family businesses !

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Sickness Funds

Providers - without risk

AOK + LKK Baden-

Württemberg

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Managing the population/programs - taking risk and sharing gain

Normal care claims

New care efforts

Shared savings

Health gain

Gesundes Kinzigtal GmbH: organizing and managing the health gain and sharing the savings

33% 66%

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September 2014 Partners No. Enrolled Insurees of AOK and SVLFG 9,547

Providers with partnership contracts

GPs, specialists, psychotherapists – ~58% of those physicians working in the region Kinzigtal Staff in the provider offices

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~ 190

Hospitals – around 85% of all cases 6

Physiotherapists 9

Nursing homes 11

Ambulatory nursing agencies/ psychosocial agencies

6

Further partners in cooperation

Pharmacies – around 70% of all pharmacies 16

Self-help groups, enterprises (Network Healthy Companies in Kinzigtal), government/ administration

48

Fitness-centres – ca. 80% in the region Kinzigtal 6

Voluntary associations, sports clubs, social clubs 37

Gesundes Kinzigtal: More than a physician network – A local network with various cooperation partners

Need for professional management, communication and relationships

Around 500 people participate as partners (~ 160 organizations)

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Triple Aim: Care, Health, and Cost improvement

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With Five Key Success Factors

Changing medicine from reacting to acute symptoms to proactive collaboration between providers and patients on joined goals

Activation of patients & insureds & healthcare professionals

Substituting medication with physical training

Scientific orientation and validation based on claims data analysis to improve health outcomes

Improving public health with prevention in community

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Basic conceptual framework

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The pillars of optimization and quality- Integrated health care programs in Gesundes Kinzigtal

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Committed network partners

Primary prevention Health programs Special Themes

Gesundes Kinzigtal

Health trainings / group activities

Club sports

Course offers (e.g. aqua fitness)

Heart failure

Metabolic syndromes

Back pain

Psychic crises

Depression

Geriatric care

etc. etc.

Health management

“World of health”

Quality indicators

Incentive program

Hildebrandt H, Schulte T, Stunder B. Triple Aim in Germany: Improving population health, integrating health care and reducing costs of care in the Kinzigtal-region – lessons for the UK? Journal of Integrated Care, Vol. 20 Iss: 4, pp.205 - 222 (2012). Emerald Group Publ. DOI: 10.1108/14769011211255249

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The voice of the participants in GK programs – Patients Advisory Committee

Every second year the enrollees of Gesundes Kinzigtal select their representatives in a meeting of members

This Patients Advisory Committee represents the voice of the enrollees of Gesundes Kinzigtal

Actually the Patients Advisory Committee consists of five elected members and one ombudsman

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Various public festivities and exhibitions to be visible and present in the community ….

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… and working closely together with municipalities, local authorities, regional sport clubs and others

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2007: „Fest der Gesundheit“, Haslach 2010: „Fest der Gesundheit“, Gengenbach 2011: „Transparente Mensch“, Haslach 2012: „Fest der Gesundheit“, Haslach „Begehbare Darm“, Haslach 2013: „Kinderfest“, Haslach 2014: „Schwimmbad-Jubiläum“, Haslach 2014: Spendenaktion zugunsten der

gesundheitsfördernden Arbeit der Vereine im Kinzigtal

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Public Health / Health Promotion Interventions – some examples

Children: Public competition of school classes towards healthy nutrition and healthy school classes (games, theatre, songs…)

Young parents: Courses in developing good parenting skills / sports courses for mothers with babies

Workers: Courses in staying healthy in shift work, stop smoking, relaxation … developing a „Network Healthy Companies“ with a systemic approach towards health promoting working places

Community: Supporting health promoting community activities – this year our participants asked us to spend 26,600 € (each could advise us for 10 €)

Sports: Training the trainer courses for voluntary sports trainer and supporting over 36 clubs and preparing specific courses for people at risk

Elderly - Helping staying at home: Offering advanced monitoring equipment for elderly or sick people helping them in situations they need support (Ambient Assisted Living)

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Different methods of evaluation of results are used

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Not enrolled insurants

P

P P

P P

P P

P P

P P

P P

All insurees with residence in the Kinzigtal region

external control group

or predicted

costs via risk adjustment

scheme

Non-Cooperating physicians

Cooperating physicians

program participants

1. Program participants vs. risk adjusted non-program participants

2. Enrolled insurants vs. risk adjusted non-enrolled insurants

3. Patients of cooperating physicians vs. patients of non cooperating physicians (attribution via number of contacts > 50%)

4. Real development versus predictions

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Triple Aim Results: Medical outcomes

45% less fractures after program participation „Strong Muscles – Solid Bones“ (n= 438) for patients with osteoporosis

1,5 years longer survival for GK-enrollees, less potential years of life lost (trend V2 Statistisches Bundesamt)

Schulte T, Pimperl A, Fischer A, Dittmann B, Wendel P, Hildebrandt H (2014) Ergebnisqualität Gesundes Kinzigtal – quantifiziert durch Mortalitätskennzahlen. www.optimedis.de

IV: 1.433,8 vs. NIV: 1427,1; Log-Rank 0,082; censoring of deceased within first 182 days as well as of health insurance changers

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Triple Aim Results: Medical outcomes

3,4% less working insurants with need for sick leave (compared to adjusted pop. of AOK overall Baden—Wuerttemberg)

24% Reduction of hospital cases for patients with mood [affective] disorders (compared to adjusted pop. of AOK overall Baden—Wuerttemberg)

Köster I, Ihle P, Schubert I (2014): Evaluationsbericht 2004 – 2011 für Gesundes Kinzigtal GmbH: AOK-Daten. Available at PMV Forschungsgruppe, University of Cologne

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Triple Aim Results: Patient Reported Outcomes

“I live healthier now“ …. Answering in a positive way is correlated with the intensity of involvement, cooperation and shared-decision making

“I live healthier now“

All respondents (2012):

… Respondents being “chronically ill”:

… R being “GK-program participants”:

… R who as well stated that “they had defined goals with GP”:

37,6 %

26,1 %

45,4 %

31,7 %

Siegel A, Stößel U (2014) Patientenorientierung und Partizipative Entscheidungsfindung in der Integrierten Versorgung Gesundes Kinzigtal. In: Pundt J (Hrsg.) Patientenorientierung: Wunsch oder Wirklichkeit?. 195-230. Apollon Bremen

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Triple Aim Results: 4.65 Mio € Delta in year 8 for 31,355 insurees of AOK

4.65 € absolute increase of the contribution margin in Kinzigtal for the whole AOK-population (total costs of care without dental)

Shared between AOK and Gesundes Kinzigtal GmbH

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Triple Aim Results: The external scientific evaluation vs. control group shows even better results (here AOK and LKK results combined)

cost savings per insured living in the Kinzigtal region in comparison to a control group drawn from AOK and LKK insurees in Baden-Württemberg* in detail

2006 2007 2008 2009 2010 2011out-patient treatment - physicians *** -8,44 -6,98 12,87 11,97 13,77 13,05medication -3,04 10,05 21,40 27,55 35,99 59,76hospital -94,62 63,75 44,76 78,07 90,28 80,47remedies*** -2,99 -3,70 -4,08 -3,90 -3,52 -2,42medical aids*** 23,93 22,38 30,44 30,37 30,73 31,15savings in € (abs.) -85,17 85,50 105,39 144,05 167,26 182,01savings (in %) -4,6% 4,2% 5,1% 6,6% 7,3% 7,9%

*) standardization: on an annual basis by age group and gender, control group: Kinzigtal **) year 2005 indexed as virtual base year, using a procentual regional factor that neutralizes the delta between control group and intervention group before intervention start ***) The following costs are projected (except costs for sickness leave, here no projection has been made). The achieved savings to the point, where the data are complete are projected to the future resp. past where data are incomplete. That means that neither an improvement in savings nor a detorioration is projected for the years and cost sectors with incomplete data. AOK: costs of out-patient treatment by SHI-accredited physicians incomplete for 2009-2011, because cost data of HZV-participants are missing LKK: costs of out-patient treatment by SHI-accredited physicians incomplete for 2004 - 2006. AOK: remedies and medical aids cost data missing for 2009-2011. AOK+LKK: no cost data for sick leave available

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Total actual costs

Savings to be shared

Health gain sharing: the risk adjusted contribution margins of the partnering health insurances

Intelligence investment: Physicians know-how to streamline processes

Know-how of the management (and OptiMedis AG)

Cost cutting agreements (rebates and/or success remuneration)

Additional payments for management and substituting actions/ prevention

Tangible investment:

Health insurance

Normally expected

costs (risk adjustedi

with Morbi-RSA algorithm)

Integrator company

The integrator company (re)invests and benefits from its success

Hildebrandt H, Hermann C, Knittel R, Richter-Reichhelm M, Siegel A, Witzenrath W. S Gesundes Kinzigtal Integrated Care: improving population health by a shared health gain approach and a shared savings contract. International Journal of Integrated Care [serial online] Vol. 10, 23 June 2010 Available from: www.ijic.org

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Structure:

Monitoring system for the physicians health services cockpit focused on the Triple Aim

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Outcome Perspective

Internal Processes How can we provide optimal care processes?

Learning and Innovation In which field can we make improvements? Is there a solid base for success in the future?

Patient Characteristics Who ist the target group and (how) do

we reach it? What morbidity do the patients of my doctor’s practice have?

Health Outcome What impact has my doctor’s practice on health outcomes?

Economical Outcome What impact has my doctor’s practice on financial outcomes?

Patient Experience What impact has my doctor’s practice on the improvement

of the individual experience of care?

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Monitoring system for the physicians health services cockpit focused on the Triple Aim

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Important but expensive: Central medical record + ICT-integration

Now: Every physician sees in his own Computer-system what the other physicians did with the patient … the medications, the goals + lab results.

Huge investment of time and of money (around 1.4 Mio € …. including the analytical Data- WareHouse even around 4 Mio €)

First requirement: Trust between providers and joint experiences in working groups etc.

Keep it simple and smart …. No second system but deep integration into the work flow

GP

SP

GP SP

PS CMR

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New developments in Kinzigtal

Creating a Training Academy for the health care professions

Building a „World of Health“ with a medical physical exercise centre

Developing a „Healthy Companies Network“

Plan: Employing young doctors to secure care

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www.gesundheitsakademie-kinzigtal.de/

www.gesunde-betriebe.net

Medizinisches Versorgungszentrum

Kinzigtal

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A new law in Germany will provide more investment funds and incentives

The „Versorgungsstärkungsgesetz – VSG“ is in negotiation and being planned to start in summer.

Less regulation + easier realization

225 M € each year for the next four years for an „Innovation Fund“ where solutions like Kinzigtal may apply for start-up-money

More pressure on Health insurances to invest in real working solutions with real returns

Social and private oriented investors are planning to back up those initiatives realizing that health care improvement is really needed and answers to a serious need of western societies

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Learnings: Success factors of the population management / integrator approach

Regional care company as “integrator”

Combination of evidence based population and

indication based improvement initiatives

Going beyond healthcare

Relationship management and communication

Balanced payment system oriented

towards achieving the Triple Aim

Comprehensive implementation of

technology: ICT & data-driven management

approach

Coopetition = cooperation and

competition through transparency and

benchmarking

Common culture and friendly interactions

Long lasting contractual relationship

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In one sentence:

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Refocusing on the Common Value in Public Health,

instead of incremental individual benefit at the expense of

the others and of the commons and continuously

explaining to each and everyone that this is in their interest

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„Transformative solutions will be needed“ says World Economic Forum (Davos)

“…The purpose of the project – and this report – is to support strategic dialogue among various stakeholders on what health systems are now, what they might be in the future and how they could adapt to be sustainable.

Sustainability is unlikely to be achieved through incremental changes.

Instead, transformative solutions will be needed – solutions that require cooperation across industry sectors and governments, and thereby challenge the current boundaries of healthcare and established norms of operation. …”

http://www.weforum.org/issues/scenarios-sustainable-health-systems

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Conclusion: The Kinzigtal way is working, its replication to other areas is possible

The contractual basis develops an intrinsic coherent interest in optimizing health care and prevention

Kinzigtal has always to strive forward with further improvements (if not it will fall back in its revenues)

The participating partners have a substantial higher income than their peers (but have to invest more time and intelligence as well)

Patients love the Kinzigtal-way and run towards those sickness funds who are partnering

Sickness funds have a substantial improved customer loyalty, education and bottom line in total health care costs

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Busse/Stahl: Comparison Gesundes Kinzigtal – Bundled Payment in NL and Integrated Care Pilots in England

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VWS/NZa feedback Apollo network

NPHF project group

Fries land

Vitaal Vechtdal & other regions

Nijkerk &

Nieuwe gein

(Model) Contracts and cases

Facilitation Acceptance

Expansion & improvement

Bottlenecks & solutions

Input & support

OptiMedis Nederland: working on adapting best practices to NL

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Appropriate integrated contracts per sub population rewarding health gains

• Fee For Service: per consultation, diagnostic test, hospital day, medication, etc.

• Pay for Performance: payment for extra activity expected to have positive health impact

• Bundled Payments: fixed fee per patient for complete care pathway and result

• Shared Savings: difference between trend and actual between insurer and HCP’s

• Partial Capitation: fixed fee per insured per year for specific disease treatment

• Global Payments: total budget per person per year for all care for that person

Years

P4P

Shared savings

Partial Capitation

Global Payments

FFS

Bundled Payment

FUTURE

PRESENT

Accountability for health(care)

Source: VEROZ.nl White paper 2014

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Six prerequisites to succeed in population-wide comprehensive integrated Health Improvement

1. A business model that has more attractive incentives and rewards than the prevailing model

2. The „integrator“ must be furnished with solid financial power and the ability to (re)invest with long-ranging contract certainty

3. The “integrator” should be constituted by co-ownership and strong basement in local physicians and some public co-ownership

4. The region should not be too large but should have some cultural regional identity with cooperating partners who trust each other

5. Data, Data, Data: only the actual operational availability of diagnosis, cost and utilization data allows for learning progress

6. Benchmarking and transparency about outcomes to the public, report cards and evaluation

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Our „take-home-message“

A clever long lasting contract, oriented towards „Integrated Chronic Care“ and „Triple Aim“ with the possibility to (re)invest and to analize the claims data, guarantees success

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„But: there is no free lunch“: Regional integrated care for a whole population and the re-integration of Public Health, health promotion and traditional health care management needs a lot of invest and courage….

… … but out of the health sciences there is so much input to be taken and the work delivers such an amount of pride, excitement and generates real value for the whole society … so it is really worthwhile

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We are very much interested in cooperation and your feedback !

Helmut Hildebrandt, Vorstand, OptiMedis AG, Borsteler Chaussee 53,

D – 22453 Hamburg e-mail: h.hildebrandt@optimedis.de

www.optimedis.de engl: www.optimedis.com

www.gesundes-kinzigtal.de

engl: www.gesundes-kinzigtal.com

See website with videos www.optimedis.nl

See website with downloads

Jurriaan Pröpper, Director OptiMedis NL, Schipholweg 103,

2316XC Leiden e-mail: jp@optimedis.nl

www.optimedis.nl