#CISummit Care Delivery Care Innovation - The discussion

Care Delivery/Primary Care Innovation Case Study

Moderator: Mohit Kaushal, MD, MBA

Executive Vice President of Business Development and Chief Strategy Officer, West Wireless Health Institute 

Christopher Chen, MD

Chief Executive Officer, ChenMed 

Frank Ingari

President and Chief Executive Officer, Essence Healthcare 

Brian Prestwich, MD

Assistant Professor of Family Medicine, Keck School of Medicine, University of Southern California 

Lonny Reisman, MD

Chief Medical Officer, Aetna 

David P Kirchhoff

President and Chief Executive Officer, Weight Watchers

2% incentive for Docs is a small number. Small number = small change.

FI: Aggregation to deal with scale. Episodes of care has issues with boundaries of care.

Capitation is the long term solution. 

LR: A continuum of solutions for delivery solutions. starting from basic EMR implementation building to full risk management/share.

AETNA doing a lot of consultation that leads to development of payment models that work for the delivery system.

Orientation around the patient is an awakening. The solution to health is not in the doc's office or hospital

FI: The model today is a reactive patient presentment model. We need to flip the model so that the provider is reaching out before the patient presents.

CC: We need a cultural change for doctors. We should expect docs to help innovate. 

BP:  Risk-based registries are critical to population care. We need time to reflect on patient story and payment options to allow e-consults.

DK:  Working with Cleveland Clinic,  State of Oregon.  We need to move to focus on prevention. eg. for avoiding diabetes.  Alignment works. Patient, Payer, Provider

FI:  Reducing obesity would have massive ROI for Medicare participants. 

LR: Technology is essential but not sufficient.  Support and incentives are a critical addition. More collaboration needed to achieve success.

 CC: After a heart attack a patient has an average of 11 drugs to take. Put the drugs in their hand don't send them to a pharmacy. This removes one barrier. 

BP:  We need to help patients do workflow on their own life/health.

BP: The LA Innovation Corridor covers 11M people. 

 What would you do to help achieve the Triple Aim:

DK: Rewire the system so that incentives align with processes.  We need proactive preventive care.

BP: HIT  that supports the patient and population view. Dashboards that guide care. Take care of patients well and the risk takes care of itself.

CC: Scaling culture is hard. We need to rewire from transactions to outcomes.

FI: Use Meaningful Use Phase 2 /3 to be more open. Allow information to flow in AND out.

LR: We need to spend more time thinking about Health - Engagement and motivation. Patients don't automatically do what the doctor suggests. 

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#CISummit: Frank Ingari - Essence Healthcare / Chris Chen of ChenMed / Brian Prestwich - Keck School of Med USC / Kirchhoff - @WeightWatchers

10:45am-12:15pm Panel 1

Care Delivery/Primary Care Innovation Case Study Moderator: Mohit Kaushal, MD, MBA Executive Vice President of Business Development and Chief Strategy Officer, West Wireless Health Institute  Christopher Chen, MD Chief Executive Officer, ChenMed  Frank Ingari President and Chief Executive Officer, Essence Healthcare  Brian Prestwich, MD Assistant Professor of Family Medicine, Keck School of Medicine, University of Southern California  Lonny Reisman, MD Chief Medical Officer, Aetna  David P Kirchhoff President and Chief Executive Officer, Weight Watchers

Larry Ingari - Essence Healthcare

Reinvented insurer as logistics and evidence provider.

Eliminating acute episodes is not enough.

Medicare Advantage  addresses flaws in original plans.

Essence provides data for free to their providers.

timely, accurate with continuous learning.

Detailed performance summaries.

Collaboration on benefit design referral and other policies.

Initiatives are driven by Care Management.

Christopher Chen - ChenMed

Another instance of a family of physicians discovering the experience of a patient.

No one accountable for care/results.

Principles:

1. Invest in patients upfront

focused on moderate to low income senior population (focus on a specific population)

2. Physician Culture - deliver outcomes and not procedures

3. Develop technology to achieve goals.

Design a one stop shop approach for a focused population.

Then you need to get access for the population. They provide transportation to/from the clinic.

Restrict panel size so patients can be seen monthly. 

Technology is designed to support the doctor patient relationship.

Brian Prestwich - Keck School of Medicine - University of Southern California

The Greater LA Care Innovation Corridor. 

Doctors need time. They need support.

Doctors need information. 

The EMR of today is completely inadequate for the family doctor. They need to be connected. They need knowledge from the patient. They need population information for comparison.

Redesigning team-based care.

Redesigning the Physician work day.

Group care works for complex patient issues.

Figure out what you want to do

Fix the care model

Implement technology to support the care model.

Educate the patient to take better care of themselves.

Make it simple to reduce the cognitive workload

David Kirchhoff - Weight Watchers

Obesity is a lifestyle issue.

It is difficult and messy

The NHS in the UK works with Weight Watchers. Doctors can provide vouchers and refer patients to Weight Watchers.

12 Session course on PCP referral. 45 UKL at no cost to patient.

A Cambridge study showed PCP+Weight watchers program is twice as effective. Doctor creates sense of urgency. Weight Watchers delivers program and payer supports. 

WW does 45,000 meetings per week globally (20k in USA)

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#CISummit Mohit Kaushal - Care Delivery/Primary Care Innovation Case Study

10:45am-12:15pm Panel 1

Care Delivery/Primary Care Innovation Case Study Moderator: Mohit Kaushal, MD, MBA Executive Vice President of Business Development and Chief Strategy Officer, West Wireless Health Institute  Christopher Chen, MD Chief Executive Officer, ChenMed  Frank Ingari President and Chief Executive Officer, Essence Healthcare  Brian Prestwich, MD Assistant Professor of Family Medicine, Keck School of Medicine, University of Southern California  Lonny Reisman, MD Chief Medical Officer, Aetna  David P Kirchhoff President and Chief Executive Officer, Weight Watchers

Lonny Reisman - AETNA:

Tiered Networks as an emerging standard. Constrained networks (to ACO as most constrained) driving quality improvements.

AETNA is building HIT tools to power ACOs.

Sharing and Interoperability is important. ETNA has acquired Medicity to provide a Health Information Exchange.

Analytics are important. 

We need precision of information. We need workflow tools to maximize performance.

AETNA has 3 models:

1. Enhanced Clinical capabilities

2. Population Management

3. White Label Payer 

Eliminating co-pays for patients have demonstrated improvements in care. ie. reduce the patients barrier to care.

Free drugs after a heart attack led to only 51% compliance. This indicates that there is far more to be done in caring for the patient.

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#CISummit @aneeshChopra is up with Ignite Talks on prizes and Challenges (@DDDiabetes, @KP JandJ

Aneesh Chopra: Rousing the crowd. Aneesh has to build on the @Todd_Park mojo.

Innovation will grow new industries and new businesses. 

America Competes gives the government new tools to spark breakthrough ideas.

Ignite Talks on Prizes and Challenges

1. Dennis Urbaniak: Sanofi - Diabetes Challenge

Crowdsourcing Health

2012 Data Design Diabetes Innovation Challenge:

1. Crowdsource applications

2. Open Submission

3. Mentorship

4. Demo Day

5. Support 

Tweet using @DDDiabetes

2. Johnson & Johnson / Janssen Healthcare 

Janssen Connected Care Challenge.

Caring for a person who has been hospitalized is very challenging. Can we develop a tool or system to help people coordinate care.

1 in 3 people discharged don't see their physician inside 30 days.

This is a $15B problem. $12B is preventable!

How do you connect caretakers, medication, therapy, physician, hospital in a coordinated care plan.

The challenge is looking for approaches to improve connected care. Prizes range from $50,000 to $100,000.

www.janssenhealthcareinnovation.com

3. James Albino - White House /  Michael Horberg - Kaiser Permanente.

Kaiser Permanente HIV Innovation Challenge

www.kp.org/hivchallenge

KP's systemic approach to HIV treatment leads the nation. mortality rates are much lower than national average. Their approach also eliminates the treatment disparities  amongst disadvantaged communities.

KP is largest provider of integrated HIV care in the USA.

Get patients diagnosed, in to care and on a course of treatment leads to better outcomes and productive lives.

Multi-disiplinary care. using the EMR, coordinated treatment.

The challenge: join KP and benefit from their lessons learned.  No cost access to the toolkit they have compiled.

Access to mentorship and treatment and care guidelines.

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#CISummit Rick Gilfillan, MD - Director CMS Innovation Center and @Todd_Park

Rick Gilfillan - Director of CMS Innovation Center with Todd_Park, CTO and Entrepreneur in Residence at Health and Human Services.

The CMS Innovation Center Approach:

Is the Triple Aim possible?

Amongst diabetics: Treatment (insulin and blood strips) = $3600 per year v leg amputation for ulcerated foot = $50,000

A system that is good at providing "care fragments" 

The Emergency Room is becoming the only viable place to get care for a growing population.

Achieving the three part aim:

1. Commitment:

2. Innovation

3. Spread the innovations with wide adoptions

Innovation approaches:

Medical Homes

Accountable Care Organizations

Bundled Payments

"No one went to school to provide fragmented, expensive care"

If something CMS Innovation Center tests something that can improve care with positive results then they can promote regulations to aodpt the new payment structures.

This provides the opportunity to move from pay for volume to pay for outcomes.

Multi-Payer Primary Care Practice

Federally Qualified Health Centers Medical Homes

Dual Eligible population: 9M have Medicare and Medicaid coverage.

Pioneer ACOs - 32 contracts to test ACO models reaching 87,000 medicare beneficiaries.

Diffusion and Scale: 

- Innovation Advisors

- Million Hearts (could save 1M lives over 5 years)

- Partnership for Patients (focusing on patient safety and care transitions)

The Innovation Challenge: $1B of awards to demonstrate new methods of care.

A large portion of the audience are interested in this challenge which closes on Friday January 27th - Tomorrow!

Data is critical. 

Todd Park now talks about how data will get to innovators.

CMS is embracing the power of Data Liberacion.

Data is rocket fuel for innovation

Strategic priority to unleash the power of CMS data to improve health care - while protecting patient privacy..

Blue Button - VA, Medicare beneficiaries can download their own personal health or claims record.

500,000 people have downloaded their data. Adoption is accelerating. This is expanding to private sector organizations. 

Robert Wood Johnson have established bluebuttondata.org

Data for ACOs

Medicare Data Sharing for Performance Measurement - these reports will be made available to the general public.

www.healithindicators.gov

These are just the beginning. Improving accessibility and serviceability of data is a core service function for CMS.

There is no problem America can't innovate its way out of - apply the innovation mojo!

Rick Gilfillan: Now is the time to decide - adopt innovation. Change the way we think. It is not abstract. It is a real issue.  Doing nothing is making the decision to standstill. 

It is not easy. it is difficult. Remember the first rule of medicine: Do no harm.

CMS pledges to be a constructive force in this change.

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#CISummit - Dr. Atul Gawande - How do doctors get good?

From the Care Innovations Summit:

Dr. Atul Gawande, Surgeon, Writer, Public Health Researcher.

How do Doctors get to be good at what they do?

In last 10 years an ordinary Family has seen a rise in pay of $23k but all but $85/month has gone to paying higher health care costs.

The same has been seen in MA in the education sector. Every penny of increased investment has been diverted to health care for teachers.

Health Care (cost) is destroying the American Dream

in 1937 (pre-penicillin days) Health Care was cheap and ineffective.Hospitalization's major benefit was food and warmth.

Since then we have discovered 13,600 diagnoses and 4,000 surgical procedures and 6,000 medications.

No other industry has to deliver on 13,600 product lines to every person in every community.

Our delivery methods have not significantly changed despite this explosion in diagnosis and treatment.

We trained and rewarded independent cowboys when we want pit crews for patients.

The medical community can't cope on their own. Clinicians are baffled by the cost discussion.

We forget the bell curve of impact and cost. The two curves do not match.
This is a sign of hope. If the curves matched we would be talking about rationing of care. But that is not the case.We need to identify the positive deviants. The most successful behave like systems and not independents.
Data is an under utilized resource in Health Care. Data is the window to answers.

HealthCare today is like driving a car with a speedo that tells what speed we were traveling 4 years ago.

The major illnesses of the 5% highest cost medicare beneficiaries in 2010:

Ischemic Heart failure 32% of all beneficiaries and 68% of high cost beneficiaries.

Airlines and Restaurants use Checklists.
Applying checklists to surgery can make a big impact. Average reduction in deaths was 47%. VA has adopted this approach. leading to 18% reduction in deaths.
Implementing Discoveries:

We have to deal with resistance.
We must change who we train, how we work together and how we get our jobs done.

Values:
1. Humility (we all make mistakes)
2. Discipline (Repeat practice)
3. Teamwork (More knowledge than we can handle alone)

We need to define what great performance and great care looks like and then design the payment system to support that outcome.

We are battling for the soul of American Medicine. The fundamental issue of this century.

In early 1900's Food was 40% of a family budget.
Government provided data. Weather, crop reports, prices etc.
Incentives: eg. Farmer cooperative banks.
Comparative Effectiveness studies. Cost effectiveness studies.

Intending to bend the cost curve they halved the cost within 20 years.

We face the same challenge in Health care today. This is a 20 year journey that starts by setting out to bend the cost curve.

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#CISummit - Marilyn Tavenner Acting Administrator - CMS

Marilyn Tavenner talking about the work of CMS in support of the Triple Aims and the Innovation Center.

Two years since Affordable Care Act (ACA) went in to law.

ACA addresses:

- Insurance companies

- Higher Quality of Care

- Improved Access to Care

- Innovation

2010: 

- Filled in the donut hole

- Created the high risk pool to serve high risk patients with pre-existing conditions.

- Children can't be blocked from coverage due to pre-existing conditions

- Medical Loss Ratio set at 80% (ie. 80% of premiums to go to care spending)

- Free health risk assessments /wellness visits.

By 2011: 22M on medicare have received at least one free service.

here to talk about 2012 and beyond.

In October hospitals will be paid based on quality of care.

- Coordinating care

- Improvements in Technology

- Changes in Delivery Systems

- Public Private Partnerships

Innovation Center:

- More than a dozen initiatives launched.

- Value not Volume and putting the patient at the center.

Don Berwick has been repeatedly acknowledge at Summit events as the master architect of the reengineering of CMS. He has been masterful in shaping the future in an entirely positive manner. 

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