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Michigan Cancer Consortium 2013 Annual Meeting
State Level Delivery System and Payment Reform Innovation
Tony Rodgers, Principal
November 20, 2013
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Key Pillars of Comprehensive Health Reform
Health Insurance Reform
Healthcare Delivery
System Design
Value Based Purchasing &
Payment Reform
Affordable Care Act
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States can be Laboratories for Delivery System and Payment Reform Innovation
Health System Transformation
Policy Alignment
Delivery System Design Payment
Models
Health IT
Performance Improvement Accountability
P4P Incentives Care
Management Partial Cap Global
Models Medical/Health
Homes ASCs ICO’s MCO
Performance Management Performance
Reporting Provider Profiling QI/PI
Population and Community
Health
Policies GME Policy Primary Care
Workforce Supplemental
Payments
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Michigan’s Stakeholder Engaged Model Planning and Design Process
Stakeholders Putting the Pieces Together
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“Collaborative adaptive leadership and intelligent
design is critical to successful delivery system redesign and payment reform.”
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Four Key Planning Steps Delivery System and Payment Reform
Vision
•Developing a common vision among stakeholders to define Michigan’s next generation delivery system and payment models
Goals
•Establishing the broad goals and aims of delivery system redesign and target performance improvements
Model Characteristics
•Articulating the key characteristics of the next generation delivery system and payment model
Model Elements
•Developing the detailed elements of the delivery system and payment model
1 2 3 4
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Creating a Common Vision of the Next Generation of
Michigan’s Healthcare Delivery System
7
Next Generation Emerging Today
• ACO, Patient Centered Medical Homes, and Pay for Performance Incentives ACO and Patient Centered Medical /Health
Homes Shared Savings Value-Based Payment and Reimbursement Performance Incentives Strengthen Quality Improvement Program Electronic Health Records and Health
Information Exchanges • Provider and Patient Relationship Greater Chronic Disease Management Engage patients / personal responsibility
shared decision making regarding health Care management and coordination Greater cost and quality accountability
• Quality Improvement and Best Practice Knowledge Diffusion
Delivery System and Payment Reforms Community Integrated Health Systems Population Based Payment Model Shared Risk & Reward payment models Long Term Health Outcome Value-Based
Reimbursement Cost Containment Focus Emphasis on Community Health Performance
• Increased Connectivity / Patient Engagement and Responsibility Interactive patient engagement tools to support
self-management & healthy living Seamless coverage continuity management Integrate beneficiary life span care management Broad use of telehealth, mobile, and social media
tools • Continuous Performance Improvement Cross Sector Linkage and Integration Rapid Cycle Evaluation and Improvement
Vision
Person/Family Centered Value Based &
Outcome Oriented
Accountable & Community
Integrated
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Establishing Broad Goals of Delivery System and Payment Reform
Michigan’s Broad Delivery System and Payment Reform Goals
1 Strengthen the primary care infrastructure to expand access for Michigan residents
2 Provide coordinated care to promote positive health and healthcare outcomes for individuals requiring intensive support services
3 Build capacity within communities to improve population health
4 Improve systems of care to ensure delivery of the right care, by the right provider, at the right time, and at the right place
5 Design system improvements to reduce administrative complexity
6 Design system improvements that keep insurance premiums affordable for individuals and employers
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Michigan’s Key Model Characteristics
Accountability Person- and Family-centeredness Community-centeredness Prevention, Wellness, and Development Focus Community Linkages Community Integration Evidence-based Payment for Value
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Delivery System Model Elements
Element Role or Function of the Delivery System Element
Person Centered Medical /Health Home
A primary care practitioner or health team that manages the care and coordinates services for panel of patients
Accountable Systems of Care Organized provider network that take responsibility for a population of assigned/enrolled patient.
Payer and Purchaser 1. Medicaid Managed Care Health Plan 2. Health Insurance Exchange Health Plans 3. Medicare Fee for Service Program 4. Medicare Advantage Plan 5. Commercial Health Insurance Health Plan 6. Self funded purchasers
Community Health Innovation Region
An organized community based organization the facilitates development of community health strategies and is an incubator for community health innovation
HUB/Community Resource Management
A organized single access point for patient and community members accessing psycho/social/economic community based resources
Health Information Infrastructure Provider
Organization that provides the infrastructure for the exchange of health information between services providers.
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Developing the Detailed Design Specifications for Michigan’s Delivery System and Payment Reforms
Person/Family Centered Care Management
Community Integrated Care Delivery &
Management
Information Technology
Performance Mgmt /
Analytics
Payment Methodology &
Management
• Expanded and strengthened Primary Care
• Assures effective PCP / Specialist coordination
• Accountable Governance
• Learning organizations
• Assures effective health risk management and cost containment
• Person centered networks designs
• Patients & networks affiliation
• Emphasis on patient & family engagement
• Focuses on Population Health Management
• Effective in Prevention & Wellness
• Invests in Community Health Capacity
• Community Accountable
• Partners with Public Health
• Life Span Care Management
• Community Resource Integrated
• Financially Aligned to Community Risk Reduction
• Integrated provider and patient portals
• Broad use of personal health record
• E-Health risk assessment and health management tools
• EHR/HIE connectivity and seamless Information Exchange
• Integrated health record
• Interactive patient care management tools
• PHR integrated patient decision support tools
• Broad use of cost effective Telehealth Remote monitoring
• Payments and reimbursement aligned to patient care and population outcomes
• Equitably shares risks and reward
• Rapid cycle performance based payment
• Payment that dynamically adjust to severity and risk factors
• Prevent fraud and abuse
• Support informed shared decision making between patient and provider
• Reduce administrative burden & cost
• Effective in the use of “big data to improve performance
• Real time performance analytics
• Person centered performance improvement
• Analytics to support effective community risk and population health management
• Computerized learning systems for improving patient management and self care
• Provider & health system public performance reporting
• Integrate performance and financial incentive systems
• Personalized consumer health analytics tools
11
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Healthcare Decision
Tools
Person to Population Analytics
Health Outcomes
Improvement
Performance improvement will require access to large scale healthcare data & analytics to support rapid cycle evaluation and knowledge diffuse, and to translate best practice into community practice application
Connecting various Sources of data and health information
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Michigan’s Healthcare Delivery System Model
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The Patient’s or Caregivers Role in the Next Generation Healthcare Delivery System
1.Communicate with provider or medical team;
2.Self-care management; 3.Shared decision making; 4.The engagement and active
participation in health and wellness;
5.Learned about health condition and raise health literacy.
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Levels of Shared Decision Making and Patient Activation and Engagement
Moving from passive
participant to starting to take a
role in key healthcare
decision making related to their health or the health of a
family member.
Proactively seeking to build knowledge of
illness or condition and what treatment
options and personal
responsibility in self care
management is required
Being able to advocate for self
or a family member in a confident and informed way.
Taking personal responsibility for
helping to achieve good outcomes for
care.
Adopting new behaviors and
self care management
that will lead to positive health outcomes and
maximizing quality of life span health.
Level 1 Level 2 Level 3 Level 4
Increasing Level of Patient Activation and Engagement
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Role of Patient Centered Medical Homes
Patient-provider partnership
Patient registry
Performance reporting
Individual care management
Extended access
Test results tracking & follow-up
Preventive services
Linkage to community services
Self-management support
Patient web portal and e-health connectivity
Coordination of care
Specialist pre-consultation & referral process
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Role of Patient Center Medical Homes in Prevention, Screening, and Early Detection
Prevention, Screening, Early Detection, and Referral: Develop effective screening strategies to increase screening (e.g. cancer) of high risk patient and early detection of disease and illness. Effective methods to increase screening in primary care settings include : Implementation of specific days devoted to prevention activities, Planned care visits should be used e-learning tools prevention, Designated non-physician staff to work with high risk patients and complete specific
prevention activities. Use a team-based model of care that includes non-provider staff such as nurses,
community health workers, and patient navigators in connecting with patients. Electronic medical records systems should have patient registries to identify at-risk
patients and generate reminders to both staff and patients of the need for preventive services and appointments.
Integrate clinical decision support functionality with EMR that provides evidence-based clinical guidelines and best practices references for screening and referral.
PCMH will address both intrapersonal (for example, fear) and systems-level barriers (for example, appointment navigation & us of community health workers) to achieving follow-up care for screening abnormalities, especially for minorities and low-income populations.
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Accountable Systems of Care Accountable Systems of Care are one of the major delivery system reform component in Michigan’s SIM delivery system model.
Provide clinical direction and administrative support for provider network
– Contracting
– Reporting
– Credentialing
– Clinical guidelines and medical direction
Train and develop staff
Quality reporting, provider performance profiling, and improvement
Provides support for population health management
Care management and coordination system support
Data collection, analysis and data management
EMR and HIE interface implementation a continuous support
Provide and train care managers
Contract with or arrange for specialists referrals, diagnostic services, community based services, and other services required to support the full continuum of care.
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The Delivery System Must Support the Health Information Infrastructure for EMR/HIE
Accountable Systems of Care must support: 1. Electronic medical record (EMR) system that are
electronically connected or integrated with the broader delivery health information system via a health information exchange or as part of an integrated EMR platform.
2. Integrated patient disease registries, 3. Medication management and e-prescribing capability 4. Integrated clinical decision support , 5. Patient portal and support the patients electronic
personal health record, 6. Quality reporting and analysis capability.
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Beneficiary /Person
Centered Impact
Organized System of
Care
Clinical Leadership
Community Integrated
Continuous Performance and Outcome Improvement
Meaningful Use of Health
Information Technologies
Knowledge Management & Dissemination
Adaptive Learning
Organization
Accountable System of Care Design Characteristics
Results In
Beneficiary/Person Centered Accountable Systems of Care Healthcare Networks
Better Care and Patient Experience
Clinical Integration and Evidence-Based Care
Patient Activation and Increased Health Literacy
Efficient Cost Effective Care and Cost Contaiment
Reduction in Health Care Cost Trends
Population Health Improvement
Expected Outcomes
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H
H
CAH
Hospital
Critical Access Hospital
PCMH
Non-PCMH
Physician
FQHC
CMHSP
Specialist
H
CAH
ASC’s
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H
H
CAH
Hospital
Critical Access Hospital
PCMH
Non-PCMH
Physician
FQHC
CMHSP
Specialist
H
CAH
HUB
HUB Community Services System
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Linking Patient/Person Centered Performance Measures with Community and Population Health Performance
Measures
Michigan’s Quality &
Performance Measures
Patient Centered
Based Outcomes
Performance Screen
Community Health Performance
Measures
• Adult Mortality Reduction •Violence Reduction •Safety •Suicide Prevention •Heart Health •Increase Activities of Daily Living •Adolescent Health •Child Health & Development
Accountable Systems of Care
Public Reporting Community Scorecards
Community Health Innovation
Region Performance
Priorities
Managing Community and
Population Health Risk Factors
Cost, Health and Population
Health
Community Based
Performance Outcomes
Innovation in Reducing Community Risk Factors
Provider Performance Reporting
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Preventive Care
Acute Care
Chronic Care
Screening Services
Community Integrated Accountable Care System of Care Model
Integrating Patient Centered Care with Primary, and Secondary Prevention
Community Health Surveillance
Community Engagement and Governance
Assessment & Referral
Resources
Community Health Innovation Region
Governance
Assessment & Referral
Process
Community Trust
Programs
Community Services and
Well Care Resources
Other Specialized
Services
Community Healthy Living Support and
Environmental Services
ACO Network
Medical Home
Public Health
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Delivery System Redesign and E-Health Connectivity
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State Innovation Model Initiative Will Spark a Revolution in the Use of Connect Technologies
E-Health Information •Electronic Personal Health Records •Electronic Health Records •Health Information Exchange
E-Health •E-Health Coaching and Support Groups •E-Learning Health and Self Care Management •Social Media and Social Marketing of Health
Telehealth and Use of Mobile Technologies •Telemedicine •In-home and on-person remote monitoring •E-Consults
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Apple’s new “i-Watch” will reportedly track heart rate and other basic metrics, is likely to be the first product and be a platform for other health-focused developers. Reports say the watch will include a 1.5-inch display and run a full version biometric tools.
Apple has staffed up with software and hardware engineers, plus medical sensor, manufacturing and fitness experts.
Apple is investing in tackling tackle sensor technologies and remote patient monitoring, wearable devices and potentially weight management.
Explosion in Development of Mobile Products for the Personal Healthcare Market
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New Provider to Patient Connectivity Tools for Patient Care Management
Partners Healthcare, in Massachusetts has a dedicated “Center “ to exploit uses mobile and other remote technologies to improve patient care and patient connectivity with their health team.
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Next Generation Technology
Accountable systems of care responsible for innovative adoption, application, and deployment the next generation of health information, telemedicine, telecommunication, and mobile technologies:
Integrated patient e-learning systems and patient portal web-based interfaces;
Support social media and social marketing functionality to link patients important health information;
Remote biometric interface capability and other remote monitoring capability;
Electronic Personal Health Record with integrated patient decision support system,
Web based community resources databases and referral tools.
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The Connected Accountable Healthcare Eco-System
Health Analytics
Acute Care
Specialty Care
Community Resources
Pharmacies Other Care
Settings
Diagnostic Services
HIT Infrastructure
Health Analytics
Shared Decision
Making Tools Care
Management
Care Coordination
E-Health
Self-Care Support
Connected Patients and Families
Person Centered Medical Home
Accountable System of Care
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SIM Model Testing
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SIM Health Care Delivery System Planning & Design, Model Testing, and Deployment
• Quality, Population Health, and Cost Performance Analysis
• Stakeholder Engaged Collaborative Planning
• State Healthcare Innovation Plan & Roadmap
• Model Test Proposal Planning and Design
Stage 1
•Model Test Implementation
•Performance Analysis and Reporting
•Rapid Cycle Evaluation and Improvement
•Ramp up to bring the test to scale
•Model Test Evaluation and Summation Report
Model Testing Stage 2
• Evaluate Deployment Strategy
• Program and Policy Recommendations
• Legislation and Regulation
• Policy Execution and Deployment
Program Deployment &
Policy Translation Stage 3
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SIM Stakeholders
& Payers
Michigan SIM Project Team
Health Data &
Analytics
2
Delivery System Design Person, Population, and
Community Centric
Outcome Driven Performance
Value Based Risk and Reward
Continuous Improvement
Behavior
Establish Model Tests Target Outcome Measures (better care, better health, lower cost)
Collect Data & Evaluate
Performance Outcomes
Determine Improvement
Strategy
1 2 3 4
Implement Improvement
Evaluate Outcomes against Target Performance Metrics
Value Based Payment
Communities
3
Michigan SIM Model Performance Analysis Feedback
Beneficiaries, Populations, Community Health Information
ASCs & Providers
PCMH and Accountable Systems of Care Innovation
Participants: Patients,
Populations, & Community
1
Michigan’s Model Testing & Continuous Improvement Cycle
Rapid Cycle
Evaluation & Improvement
Populations Patients
Major SIM Model Test Design Elements
C D
4
Rapid Cycle Evaluation and Improvement Process
B A
SIM Testing Award
$
$ $
Innovation &
Improvement
Continuous Learning
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Questions?
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