shift from healthcare to population health

The Paradigm Shift from Healthcare to Population Health

Bechara Choucair, M.D.SVP, Safety Net and Community Health

@choucair#PPBmeeting

May 23, 2016

The Practical Playbook National Meeting

2©2016 Trinity Health - Livonia, Mich.

Healthcare trends that affect us all:An urgent need for a paradigm shift

3©2015 Trinity Health - Livonia, MI

U.S. – Spending More for a Shorter Life

The Cost of a Long Life

Per C

apita

Spe

ndin

g

Aver

age

Life

Exp

ecta

ncy

UnitedStatesLife Expectancy Per Capita Spending

(International Dollars)

1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023

1965: $42B1975: $134B

1985: $445B1995: $1T

2005: $2T

2015: $3T

2020: $4.3T

2023: $5.2THistorical Total Expenditures


CMS Projects Health Expenditures to Grow at an Average Rate of 5.7%,1.1% Points Faster than GDP Growth

To put this into context, if the 2013 US health care spend of $2.793T was its own country it would be the 6th largest country in the world by GDP, larger than the United Kingdom, Russia, India or Canada

The health spend as a percent of GDP is expected to rise to

19.3%up from 17.2% in 2012

by 2023


PerspectivesIf health care costs in Medicare and Medicaid grow over the next 40 years as rapidly as they did over the previous 40 years, those two programs will grow from under 5% of the economy today to 20% of the economy by 2050. That is the entire size of the federal government today and is significantly larger than anything else affecting the federal budget. It is the fundamental long-term fiscal challenge facing this country.

“”— Peter Orszag, former Director of the

Congressional Budget Office (CBO).

"Medicare and Medicaid are the single biggest drivers of the federal deficit and the federal debt by a huge margin."

— President Barack Obama

“Medicare and Medicaid will cost taxpayers roughly $1 trillion this year alone. Unless reforms are enacted, entitlements are on track to consume all tax revenues before today‘s 25 year-olds are eligible for Medicare. The status quo is empirically unsustainable.”

— Congressional Budget Office

There are 76.4 million Baby Boomers according to the U.S. Census Bureau

For each of the next 20 years, 3 million Baby Boomers will reach retirement age


The Upside of the Iceberg is Provider’s Opportunity

By 2030, one in five Americans will be a senior citizen and require significant health care services.


Costs and Diagnosis of many Chronic Diseases are Expected to Rise Driven in Part by the Baby Boomers Becoming Seniors Between 2011 and 2029.

Hospitals performed twice as many knee replacements surgeries as they did two decades ago with replacement projected to

reach 3.5M per year by 2030 according to a 2012 JAMA study.

By 2029, when the last round of boomers reaches retirement age, the number of Americans 65 or older will climb to more

71 millionup from about 41 million in 2011 according to Census Bureau estimates.

73%increase The number of new cancer cases could

increase 45% by 2030 according to a 2014 ASC Oncology study.

The cost of heart disease in the U.S. will triple by 2030 according to a 2011 study commissioned by the American Heart Association.

More than 50% of Americans could have diabetes or prediabetes by 2020 according to a 2010 UnitedHealth Group study.


A pivotal transformative moment:The shift to population health is an opportunity we cannot afford to miss


The Marketplace Demands Fundamental Change in How We Operate and What We Produce

Producer-Centered

People-Centered

Driv

ers

Retail Health Market

Value Networks

Transparency

Financial Incentives

PopulationValue

ServiceVolume

TOMORROWTODAY


Our People-Centered Vision Will Produce the Population Health Dividend – Real Savings from the Triple Aim

Producer-Centered Care

People-Centered Care

Time

Hea

lth C

are

Spe

ndin

g

DIVIDEND

Note: Dividend similar to model cited in “Eliminating Waste in US Health Care.”

Berwick, Donald M., Andrew D. Hackbarth, "Eliminating Waste in US Health Care," JAMA 307, no. 14 (April 11, 2012): 1513-6.


Trinity Health:We are transitioning to a People-Centered System

30 million peopleWe serve diverse populations, with over

in our communities

As a mission-driven innovative health organization, we will become the national leader in improving the health of our communities and each person we serve. We will be the most trusted health partner for life.


Our Vision: What We Aspire to Be … and What We Are Becoming …

Our Mission Drives Our Vision and Strategy

We, Trinity Health, serve together in the spirit of the Gospel as a compassionate and transforming healing presence within our communities.

Our Core Values

ReverenceCommitment to those who

are poorJustice Stewardship Integrity

©2015 Trinity Health - Livonia, MI 13

Building a “People-Centered Health System” together

Better Health • Better Care • Lower Costs

Efficient & effective care management initiatives

Efficient & effective episode delivery

initiatives

Serving those who are poor, other populations, and impacting the social determinants of health

People-Centered Health System

Community Health & Well-being

Population Health Management

Episodic Health Care Management for

Individuals



Building a “People-Centered Health System” Together




initiatives

Serving those who are poor, other populations, and

impacting the social determinants of health





Individuals

*Owned, managed or in JOAs or JVs.

**Operations are organized into Regional Health Ministries ("RHMs"), each an operating division which maintains a governing body with managerial oversight subject to authorities.

Our 21-State Diversified Network

Home Care & HospiceLocations Serving 116 Counties47

Continuing Care Facilities59PACE CenterLocations14

Hospitals* in 20 Regional Health Ministries**92

Employed Physicians 3.9K

Affiliated Physicians23.9K



We operate one of the largest clinical episode payment programs in the nation• 43 Model 2 Bundled Payment for Care Improvement (BPCI) hospitals• 13 Model 3 Skilled Nursing Facilities (SNF)• 2 Comprehensive Joint Replacement (CJR) sites• 22,400 total annual episodes for all three programs

BPCI

SNF

CJR


We are working to improve care across clinical conditions with 43 of 48 possible bundles

(in millions)Total Program Size: $550m






initiatives







Individuals

We continue to invest in increasing attributed lives and building capabilities

FY14 FY15 FY160

5

10

15

20

25

30

35

$9,000,000

$19,000,000

$29,000,000

$39,000,000

$49,000,000

$59,000,000

$69,000,000

$79,000,000

$89,000,000

FY14 FY15 FY16

Total Number of ACOs, Attributed Livesand Annual Investment

Attributed LivesACOs Annual Investment

Since FY14, Trinity Health has invested over $90M in support of population health management efforts

Investments have promoted continual growth in both MSSP and commercial ACOs

$16.5M

$25.0M$48.9M

34 ACOs

30 ACOs11 ACOs

1,245,7501,121,000

640,000



Expanding ACO programs are the primary driver of APM growth• 14 Medicare Shared Savings Program ACOs• 5 markets partnering as a Next Generation ACO • Participating in 98 non-CMS APM contracts• 13.8K physicians participating in our Clinically Integrated Networks

accountable for 1.2 million livesMedicare Shared SavingsNext Gen ACO

Trinity Health made an initial investment in ACOs of $16.5M in FY14

Of the total $44.2M generated, $16.9M of the savings was shared with Trinity Health ACOs

Our initial ACO investments have yielded positive shared savings

Investment in ACOs

Total Savings Generated

Series1

$16.5M$27.3M

Payer Share

$16.9MACO Share

$44.2M


IT infrastructure and data-driven claims analysis

Combining internal claims data platform and analytic resources with

industry-recognized tools to report provider performance across the enterprise to provider

levels

Standardized care management

process across the continuum

Maximize efficiency in post-

acute and SNF care

Reduce unnecessary or avoidable

hospitalizations

New operating capabilities improve care and lower cost for patients in ACOs

Targeting high risk patients through

predictive modeling and coordinating patient

care through multidisciplinary teams

at the site of care

Identifying clinicians to focus on SNF population

and collaboratively manage transitions

alongside BPCI teams, utilizing home care

partnerships

Improving access to primary and specialty

care providers, engaging hospitalists in adhering

to transitions of care processes







initiatives







Individuals

Community Engagement:Clinical Services:


Efficient & Effective Care Delivery through Trinity’s

Safety Net System

Triple Aim Better health Better care Lower costs

Efficient & Effective Wrap Around Services Focusing on the Vulnerable & the Poor

Community Transformation:

Community Building Focusing on Built-Environment Economic

Revitalization, Housing, & other Social Determinants of Health

Innovation in Care DeliveryInnovation in TechnologyInnovation in Financing

Transforming, Healing Presence in the Communities We Serve





Safety Net System









Dual eligible beneficiaries are among the poorest and sickest beneficiaries covered by either program.

Most have multiple chronic conditions.

Nearly half have significant mental illnesses.

In 2013, over 10.7 million individuals were dually eligible for Medicare and Medicaid benefits.

Transforming Safety Net Care with a Focus on the Duals


©2014 Trinity Health. All Rights Reserved. 28Innovation Council - Internal ©2015 Trinity Health - Livonia, MI

Nationally, Duals accounted for a total of $284.5B in spending in FY ’10. Today, spending is estimated to exceed $300B.

Spending on the “Duals” accounts for approximately 2% of GDP.

Trinity Health provides care to more than 207k Dual-eligible patients, representing $1.5 Billion in acute care revenue, annually.


Spending on Dual-eligible Patients is High

Innovation Program – Internal @2016 Trinity Health – Livonia, MI 28


http://trinityhealthchallenges.org

May 2, 2016 Challenge launch

June 10, 2016 Letter of Inquiry (LOI) deadline

July 15, 2016 Notify if invited to complete an application

August 19, 2016 Application deadline

September 26, 2016 Innovation Council meeting/ virtual showcase

October 15, 2016 Announce awards!

3030

Challenge Timeline

©2016 Trinity Health - Livonia, Mich.




Safety Net System










What Drives Good Health Outcomes? Access and Quality of Care ≈ 20%

Self-Referral or by Family

or FriendHomeless

Shelter

Community Transport Services

Independent Physicians

Our Desired Future:Better Health, Better Care, Lower Cost

33

Inpatient Acute Care

Continuing Care

EDEmployed & Independent Physicians

HUBCHWs &

Data

Medication Assistance

Insurance Enrollment

Pregnancy Assistance

Social Services

Care Management Programs

(e.g., Faith Nursing; Complex Care)

Integrated Delivery Network

NOTE: Examples of HUB services. Many

others are sponsored by the community/RHM.

Nature of our Ministry:Community at Large (501r)

Behavioral Health

Social Determinants(e.g., Race/Ethnicity,

Gender, Income Level, Language, Literacy, Living

Location)

Data DataACOSample Referral Sources



We Can Make a Real Difference in Patients’ Lives

Muskegon Health ProjectPathways to a Healthy Pregnancy Muskegon, MI

Katrena H.Patient

Ka’Ziya H.Baby&

Pre-Community Health Worker Involvement

• Homeless• High-risk

pregnancy• Needing

prenatal care

Post-Community Health Worker Involvement

• Has housing and resources for new home

• Received prenatal care• Delivered a healthy baby

Before we met you, we were homeless and we were going from place to place.“ ”- Katrena H.

Deployment of 50 Community Health Coordinators

Part of a 2015 AmeriCorps Partnership

Challenge Grant

Community Health

Workers

Up to 10 CHWs

deployed in each targeted

MSSP and BPCI program

Focus on the Duals

Advanced analytics to

identify highest-risk

patients

Deploy CHWs & HUB / Pathways

Model to address social needs

Community Engagement


Measuring ImpactExisting MSSP ACO metrics / dashboards will be used to evaluate the impact of deploying up to 10 CHW at each of the 6 targeted ACOs.





Safety Net System









Health Does Not Begin In A Doctors Office…

Access to healthy and affordable food

Built-environment

Race / Ethnicity

Economic opportunity

Educational opportunity

Root Causes of Good vs. Poor Health

Safe places for kids to learn and play

Food and beverage environment in schools

Socioeconomic status / Income

Other social determinants of health

Clinical care (just the tip of the iceberg)



Anticipated investment of $80 million over 5 years in community health interventions.

Funding local partners with Several national partners at the table.

Applications are led by Community Coalitions, Local public health agencies & Trinity Health Ministries

$17.5 M

$22.

5 M

$40 M

Transforming Communities Funding OpportunityLaunched in Nov 2015


• Boise, ID (Promise Partnership)

• Maywood, IL (Proviso Partners for Health)

• Silver Spring, MD (Healthy Montgomery)

• Springfield, MA (Live Well Springfield TCI Partnership)

• Syracuse, NY (Syracuse Health Coalition)

• Trenton, NJ (Trenton Health Team)

Six Communities Selected to Be Funded:


• Implementation of Tobacco 21 policy

• Development/ implementation of Complete Streets Policies

• Implementation of Nutrition Standards in Head-start & Daycare

• Enhancement of Breastfeeding Policies

• Expanding Physical Activity School Board Policies

• Implementing Food and Beverage Standards/Policies in Schools

Select Strategies to be Implemented Across all Six Communities


Tobacco policy work is integral to our Community Health and Well-Being strategy.

The longevity gaps in America are growing, not shrinking.

CDC researchers have concluded disparities in tobacco use account for 20% to one-third of growing life expectancy gaps.

Living in locations that have not adopted strong tobacco control measures is directly correlated with growing health disparities and longevity gaps.

Our commitment to vulnerable populations, especially people who are poor, demands action.


Our Tobacco Policy Focus

• Pass and/or Strengthen Clean Indoor Air Laws

• Tobacco Free Campus Policies

• Tobacco 21: Raising the Legal Purchase Age to 21

Community Transformation

©2016 Trinity Health - Livonia, MI

44

of Americans live in states with strong state-level protections. Everyone else relies on local governments to close the gap, or must advocate for state-level changes.

53%

Source: Americans for Non-Smokers Rights.

6 States In Our Network Diversified Network

Loopholes for many workplaces and bars

Loopholes for bars

Loopholes for barsand restaurants

No state law!

states within our footprint have weak clean indoor air laws for combustible cigarettes6

Strong state law

A Patch-Work Quilt of SmokeFree Laws Leave Many Behind

Institute of MedicineTobacco 21 Will Reduce Smoking and Save Lives


decline in smoking initiation by 15-17 year olds

25% overall drop in smoking prevalence

12% reduction of smoking related deaths

10%

For kids alive today, 4.2 million years of life would be saved by virtue of this logical, simple policy change.

Other Important Impacts…

Decline in premature births12% Drop in SIDS cases16%

©2015 Trinity Health - Livonia, MI

Tobacco 21: Over time…


In 2016, alone, we’ve experienced big wins in many of the communities we serve.

• January 11: New Jersey passed Tobacco 21 law (pocket veto)

• March 16: Chicago passes Tobacco 21 and other historic measures

• March 29: South Bend passes state’s strongest smoking ban

• April 12: Washington, D.C. Congressional briefing likely to result in several additional co-sponsors on Federal legislation

• April 26: Albany County passed Tobacco 21 (bill not yet signed)

• May 10: California Tobacco 21 and other historic bills signed into law

• May 18: Illinois Tobacco 21 passed out of the Senate

Building a “People-Centered Health System” together




initiatives

Serving those who are poor, other populations, and impacting the social determinants of health





Individuals


Discussion…

@choucair#PPBmeeting