1 The Road to Population ManagementSurvival and Beyond The Road to Population Management An innovative model for community hospitals and health care systems Health Care Steven M. Berkowitz, MD SMB Health Consulting Austin, TX I Never Signed Up for This !
2 Survival and Beyond “It is not necessary to change. Survival is not mandatory.” W. Edwards Deming “All organizations are perfectly designed to get the results they are now getting. If we want different results, we must change the way we do things.” Jim Northup
3 2012- 2016 Clients- Two Lessons LearnedFirst, every hospital is unique. Second, every hospital is dealing with the same issues.
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5 You can always count on Americans to do the right thing… …after they’ve exhausted all the other possibilities !!” Winston Churchill People do not change until the pain of staying the same… … exceeds the pain of changing. Anonymous
6 The Road to Population ManagementThriving in an Era of an Ever-Competing Health Care Dollar Enterprise-wide Cost Reduction Transparency as the Way to do Business Implementing guidelines and best practices Excelling at Pay for Performance Recognizing and Implementing New Technology Achieving Engagement and Alignment of all Stakeholders Health Care
7 The Road to Population ManagementThriving in an Era of an Ever-Competing Health Care Dollar Enterprise-wide Cost Reduction Transparency as the Way to do Business Implementing guidelines and best practices Excelling at Pay for Performance Recognizing and Implementing New Technology Achieving Engagement and Alignment of all Stakeholders Health Care
8 Keep your feet in both boats !!Volume Still Rules !! Keep your feet in both boats !!
9 Remember, dinosaurs prospered for 400 million years!Is the Community Hospital a Dinosaur? Remember, dinosaurs prospered for 400 million years!
10 Defining the Role of the Community HospitalKeep the Care in the Community (As long as that care is safe!) Community Hospital Medical Home (Management of outflow and recapture)
11 The Role of Transparency on Volume and Market ShareThe availability of public data on outcomes, patient experience and cost will change the strategies to increase volume and market share
12 Increasing Volume and Market ShareWho is Your Competitor... The role of Transparency The Old Strategic Planning Process: Step 1- Demographic need Step 2- Financial feasibility Step 3- Build it and they will come !
13 Increasing Volume and Market ShareWho is Your Competitor... The role of Transparency The New Strategic Planning Process Step 1- Demographic need Step 2- Financial feasibility Step 3- The need to excel in public data Outcomes Pt Experience Cost Step 4- Only then, will they continue to come !!
14 Volume Still Rules !! But, expand present and future Service Lines on the basis of providing Value!!
15 The Road to Population ManagementThriving in an Era of an Ever-Competing Health Care Dollar Enterprise-wide Cost Reduction Transparency as the Way to do Business Implementing guidelines and best practices Excelling at Pay for Performance Recognizing and Implementing New Technology Achieving Engagement and Alignment of all Stakeholders Health Care
16 Job One !! There will be a focus on Cost Control like we have NEVER seen before in our careers
17 Health Care Costs Per Capita OECD
18 Per Capita Health Care Costs by AgeFischbeck, 2009
19 Cost Reduction… The Biggest Challenge to the TeamPhysician Hospital Other Rx Admin Today’s Health Care Costs ????? Post- Reform Health Care Costs Cost Reductions
20 Cost Reduction… The Biggest Challenge to the TeamPhysician Hospital Other Rx Admin Today’s Health Care Costs ????? Post- Reform Health Care Costs Cost Reductions Any decrease in health care expenditures is a pay cut for somebody in health care !!
21 The Road to Population ManagementThriving in an Era of an Ever-Competing Health Care Dollar Enterprise-wide Cost Reduction Transparency as the Way to do Business Implementing guidelines and best practices Excelling at Pay for Performance Recognizing and Implementing New Technology Achieving Engagement and Alignment of all Stakeholders Health Care
22 Transparency is the friend of the Community HospitalTransparency… This Train’s Left the Station The Good, the Bad, and the Ugly The Good Transparency is the friend of the Community Hospital The Bad The Ugly
23 Transparency… This Train’s Left the Station The Good, the Bad, and the UglyHuge gains in quality and patient experience The Bad The Ugly
24 Value Based PurchasingThe increasingly informed consumer will make health care decisions on the basis of VALUE VALUE = Outcomes + Pt Experience Cost
25 Read all about it !! April 2005
26 Core Measures: Heart Attack Heart Failure PneumoniaSurgical Care Improvement HCAHPS
27 CMS Core Measures– the Top Decile
28 Core Measures: Heart Attack Heart Failure PneumoniaSurgical Care Improvement HCAHPS Goal: 100% Compliance !! Standard of Care ? !!
29 Patient Experience- HCAHPs
30 Data Transparency- A Game ChangerThat which is measured, tends to improve. That which is measured publicly, tends to improve faster. “What we concluded was that even when hospitals know their performance is not good, that's not sufficient motivation for them to do something. Making it public made a big difference in motivating them to improve.” Judith Hibbard, Health Affairs 2003
31 Data Transparency- A Game ChangerTransparency is the best thing that’s happened to quality since antibiotics... …by decreasing variance and improving results S Berkowitz, 2006
32 …Or you’re getting worse.If the other guy’s getting better, then you’d better be getting better faster than that other guy’s getting better… …Or you’re getting worse. Tom Peters
33 Transparency… This Train’s Left the Station The Good, the Bad, and the UglyHuge gains in quality and patient experience The Bad The Ugly
34 Transparency… This Train’s Left the Station The Good, the Bad, and the UglyHuge improvement in quality and experience The Bad Tremendous resource drain on system The Ugly
35 The Cost of TransparencyHospital and physician group FTEs Data abstraction, collection and reporting Clinical reviews by staff The increasing role of the physician in performance improvement Hospital and physician capital costs IT Systems The law of diminishing returns: The high cost of marginal improvement
36 Transparency… This Train’s Left the Station The Good, the Bad, and the UglyHuge improvement in quality and experience The Bad Tremendous resource drain on system The Ugly Potential consequences of price transparency
37 Patient pays more out of pocketA Game Changer for 2015 The Rise of High Deductible Plans Patient pays more out of pocket Higher Deductibles/ Co Pays Employer Cost Shifting Health Insurance Exchanges Consumer Demand for Price Transparency
38 Average Single Premium DeductibleKaiser HRET, 2013
39 From the Standpoint of the ConsumerThere will be a demand for price transparency by the consumer more than ever before
40 The Road to Population ManagementThriving in an Era of an Ever-Competing Health Care Dollar Enterprise-wide Cost Reduction Transparency as the Way to do Business Implementing Guidelines and Best Practices Excelling at Pay for Performance Recognizing and Implementing New Technology Achieving Engagement and Alignment of all Stakeholders Health Care
41 Beta-Blocker for Acute MIThe Evidence is Published
42 Using Transparency to Improve PerformanceImplementing Best Practices Implement the Guidelines Recommended by your OWN Specialty Society
43 Using Transparency to Improve PerformanceImplementing Best Practices Guidelines for Guidelines There will be MORE guidelines in clinical medicine Guidelines were NEVER intended to apply to all patients and do NOT take the place of individual physician judgment Guidelines will CHANGE and IMPROVE with time Expect physicians to occasionally deviate from guidelines in the daily practice of prudent medical care When so… … DOCUMENT In the medical record that: The patient was seen and evaluated The options were thoughtfully considered The best clinical judgment was used Discussed with the patient
44 What Can we Learn from the Airline Industry ?Elimination of Ambiguity “the elimination of ambiguity is consistently cited as a key factor in protocol success and safety” Most medical guidelines are based upon ambiguity as a guiding principle of protocol development Degani and Weiner 1993
45 Example: Oxytocin Treatment Guidelines ACOG 2006 Compendium“Any of the low or high dose regimens outlined in table 2 are appropriate” (0.5 – 6 mU/min every min) “Each hospital’s OB/Gyn department should develop guidelines for preparation and administration of oxytocin” “The uterine contractions and fetal heart rate should be monitored closely” Evidence-Based Medicine
46 Example: Postdates Guidelines ACOG 2006 Compendium“ Women with post-term gestations who have unfavorable cervices can either undergo labor induction or be managed expectantly” “Delivery should be effected if there is evidence of fetal compromise….” Evidence-Based Medicine
47 Use any settings of the plane’sHow to Land a 747 in a Strong Cross Wind* *(Had It Been Written by ACOG) Use any settings of the plane’s instruments you feel like Every airline and pilot can do it differently Be really careful as you get close to the ground Steve Clark, MD
48 Do Guidelines Help or Hurt?“Yeah, but Pilots do not have to worry about Malpractice Suits” Obstetrician, Texas
49 What is Evidence-Based Medicine ?Evidence based medicine does not mean: Unless you can prove it with multiple prospective randomized-double blind-placebo-controlled cross- over trials, it’s OK to do anything you feel like Evidence based medicine does mean: Where there is clear evidence of superiority of one method over another, use it !
50 More than Just an EMR The Future of Databases Descriptive PredictivePrescriptive ICD-10 Improved EMRs Big Data Improved Clinical Databases Generation 1 Generation 2 Generation 3 What Happened What May Happen What Do We Do?
51 More than Just an EMR The Future of Guidelines Real Time Multi-SystemGeneral Disease Guidelines Individual Pt Guidelines Real Time Prescriptive Multi-System
52 Using Transparency to Improve PerformanceImplementing Best Practices We keep missing the point….. Simply put… Evidence-based guidelines: reduce adverse outcomes ! improve patient care ! Adverse Outcomes evidence based guidelines
53 The Road to Population ManagementThriving in an Era of an Ever-Competing Health Care Dollar Enterprise-wide Cost Reduction Transparency as the Way to do Business Implementing guidelines and best practices Excelling at Pay for Performance Recognizing and Implementing New Technology Achieving Engagement and Alignment of all Stakeholders Health Care
54 Using Transparency to Improve PerformanceExcelling at Pay for Performance Can all hospitals in the U.S. be in the top decile? Can we all be 5-stars? What do we do?
55 Why are CMS Core Measures Important? Serving Multiple MastersEvidence-based good for the patient Publicly available marketing/ PR Effect reimbursement dollars $$ Ultimately, SURVIVABILITY in Health Care Reform
56 Using Transparency to Improve PerformanceExcelling at Pay for Performance Core Measures HCAHPS Re-admissions Hospital Acquired Conditions Meaningful Use
57 Using Transparency to Improve PerformanceExcelling at Pay for Performance Core Measures HCAHPS Re-admissions Hospital Acquired Conditions Meaningful Use 5 – 10 % of Total Medicare… By FY 2017: Or more !!
58 Excelling in Pay for PerformanceFrom Process Outcomes and Efficiency
59 Using Transparency to Improve PerformanceExcelling at Pay for Performance Applicability for Value Based Modifiers: Physicians in groups > (based upon 2013 performance) Physician groups All physicians Value Based Penalties: 1%- 2015, 2%- 2016, 4%- 2017… 10%- 2020, 12%- 2021 If practice did NOT participate in PQRS in 2013, drop 1% in 2015 and 2% in 2016 Does NOT apply to physicians in ACOs or Comprehensive Primary Care Initiative
60 The Road to Population ManagementThriving in an Era of an Ever-Competing Health Care Dollar Enterprise-wide Cost Reduction Transparency as the Way to do Business Implementing guidelines and best practices Excelling at Pay for Performance Recognizing and Implementing New Technology Achieving Engagement and Alignment of all Stakeholders Health Care
61 State of the Art Information SystemsThe EMR will do for health care What the assembly line did for manufacturing
62 The Integration of Big Data into Health CareMore than Just an EMR The Integration of Big Data into Health Care Data volume continues to double every 18 months
63 VALUE = Outcomes + Pt ExperienceTechnology Assessment Committee Strategic Analysis of VALUE What is the Value of the New Technology? Does the new technology demonstrate: Improvement in Quality ? Improvement in Patient/ Caregiver Experience ? Cost Effectiveness ? VALUE = Outcomes + Pt Experience Cost
64 Utilization of a New TechnologyNatural History Through Time 1. Period of Accelerated Growth 2. Period of Decline 3. New Equilibrium Introduction of Technology Event Time Product Utilization
65 Utilization of a New TechnologyNatural History Through Time Initial clinical studies encouraging Overzealous extrapolation of those studies Desire of physician/ patient to be “state of the art” Aggressive product marketing to all stakeholders Desire to capture early revenue and market share Presence of a prevalence pool of patients Market over-corrects upward 1. Period of Accelerated Growth 2. Period of Decline 3. New Equilibrium Introduction of Technology Event Time Product Utilization
66 Utilization of a New TechnologyNatural History Through Time Event-- sudden unexpected bad outcome or study Overly aggressive publicity/ interpretation of the study or outcome Fear of product liability/ lawsuits Regulatory cautions or sanctions ensue Market over-corrects downward 1. Period of Accelerated Growth 2. Period of Decline 3. New Equilibrium Introduction of Technology Event Time Product Utilization
67 Utilization of a New TechnologyNatural History Through Time 1. Period of Accelerated Growth 2. Period of Decline 3. New Equilibrium Introduction of Technology Event Time Product Utilization Follow-up data reduces risk Evidence-based indications are determined Presence of incidence pool of patients Technology use equilibrates to “baseline”
68 Telemedicine Practicing Medicine from the Smart Phone
69 Telemedicine The Brave New WorldCurrent Challenges for Telemedicine: Ensuring a quality product Licensing issues Reimbursement Indemnification A Game Changer: Local Telemedicine !!
70 Genomic Testing Predicting the FutureCarrier Status Cystic Fibrosis Huntington’s Disease Risk of Disease Cardiovascular disease Diabetes Alzheimers Breast/ ovarian cancer Colon cancer Response to Therapy/ Optimal Drug Treatment Cancer Heart Disease Pain Management
71 Reasonable PreventionWhen do preventive measures make sense? Length of life Quality of life Does early detection make a difference? Is the disease treatable/ curable at point of detection? Lead time bias Length time bias How does detection effect the delivery system?
72 The Road to Population ManagementThriving in an Era of an Ever-Competing Health Care Dollar Enterprise-wide Cost Reduction Transparency as the Way to do Business Implementing guidelines and best practices Excelling at Pay for Performance Recognizing and Implementing New Technology Achieving Engagement and Alignment of all Stakeholders Health Care
73 With Whom do you Partner ?Community Hospitals and Systems Services not offered locally Specialists IT Capabilities Mgmt Services Branding Capital System Community Hospital Patients ! Downstream Services
74 With Whom do you Partner ?Community Hospitals and Systems Independent Affiliation Joint Venture Merge Close Down
75 With Whom do you Partner ?Community Hospitals and Systems Services not offered locally Specialists IT Capabilities Mgmt Services Branding Capital System Community Hospital What is the LEAST disruptive solution that will accomplish your needs Patients ! Downstream Services
76 Hospital Physician RelationshipsEmployment does NOT equal Alignment Employment does NOT equal Engagement Simple Fact: Hospitals and Physicians do best when both are aligned and engaged
77 Physician CompensationMean Compensation Medscape
78 The True Value of Partnership….Somewhere in the Atlantic.…
79 Clinical and Structural Reform The Icing on a Two-Layered CakeClinical Reform Structural Reform Compensation Reform Payment Reform Public Sector Private
80 The Road to Population ManagementThriving in an Era of an Ever-Competing Health Care Dollar Enterprise-wide Cost Reduction Transparency as the Way to do Business Implementing guidelines and best practices Excelling at Pay for Performance Recognizing and Implementing New Technology Achieving Engagement and Alignment of all Stakeholders Health Care
81 The Road to Population ManagementThriving in an Era of an Ever-Competing Health Care Dollar Enterprise-wide Cost Reduction Transparency as the Way to do Business Implementing guidelines and best practices Excelling at Pay for Performance Recognizing and Implementing New Technology Achieving Engagement and Alignment of all Stakeholders 8. Can You Successfully Implement these Seven in the Next 3-5 Years ? Health Care
82 The Need to Change When you're finished changing, you're finished.Ben Franklin
83 To the world you may be just one person, But to one person you may just be the world Unknown