Idaho Association of District Boards of Health Annual Conference

June 14, 2018

Ted Epperly, MDPresident and Chief Executive Officer | Family Medicine Residency of Idaho, Boise, IdahoClinical Professor of Family Medicine | University of Washington School of MedicinePast President and Past Chairman of the Board | American Academy of Family PhysiciansCo-Chair, Center on Care Delivery and Integration | Patient Centered Primary Care CollaborativeBoard Member | Accreditation Council for Graduate Medical EducationChairman | Idaho Healthcare Coalition Member | Council of Graduate Medical Education

SHIPThe Past, The Present

and The Future

“It was the best of times, it was the

worst of times, it was the age of wisdom, it

was the age of foolishness.”

Charles Dickens

28.5 Million Uninsured*

– (Down from 18% to 9%)

Wrong Focus

– Disease Instead of Health

Wrong Delivery Model

– Not Enough PCP’s

– Poor Access

Staggering Costs

Quality Problems

Health Care Insurance Problems

Major U.S. Health Care Problems

SOURCE: Kaiser Family Foundation Key Facts about the Uninsured Population, September 2016. http://files.kff.org/attachment/Fact-Sheet-Key-Facts-about-the-Uninsured-Population

In An Average Month:

White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med 1961;265:885-892.Green LA, Fryer GE, Yawn BP, Lanier D, Dovey SM. The ecology of medical care revisited. N Engl J Med 2001;344:2021-2025.

$3,000,000,000,000

National Health Spending in Billions

$27 $75$255

$721

$1,370

$2,025

$2,496

$2,880

$3,197$3,351

$3,731

$4,198

$4,733

$5,022

$5,322

$5,631

1960 1970 1980 1990 2000 2005 2009 2013 2015P 2016P 2018P 2020P 2022P 2023P 2024P 2025P

Note: Selected rather than continuous years of data are shown prior to 2000. Years 2015 forward are CMS projections. Source: Office of the Actuary in the Centers for Medicare & Medicaid Services. 7/14/2016. cms.gov

Health Spending Everything Else

1935 3.8% GDP 2009 16% GDP

2025 25% GDP2082 50% GDP

Pinball

Actual Causes of Death in the U.S.

Behaviors

40%

Genetics

30%

Socioeconomic

s

15%

Medical Care

10%

Environment

5%

McGinnis JM, Foege WH. Actual Causes of Death in the United States. JAMA 1993;270:2207-12.

Mokdad AH, Marks JS, Stroup DF, Gereberding JL. Actual Causes of Death in the United States, 2000. JAMA 2004;291:1230-1245.

Three Behaviors:

– Physical Inactivity

– Poor Nutrition

– Tobacco Use

Four Chronic Diseases: – Cancer

– Heart Disease and Stroke

– Pulmonary Disease

– Diabetes

Fifty Percent of Deaths

Preventable Causes of Death3-4-50

“Insanity: Doing the same thing over and over again and expecting different

results.”Albert Einstein

“Nobody knew health care could be

so complicated.”Donald Trump

February 28, 2017

What Improves Health Care Outcomes the Most!

1. Some type of insurance coverage.

2. A usual source of care.

Disparities in Patient Experiences, Health Care Processes, and Outcomes: The Role of Patient-Provider Racial, Ethnic, and Language Concordance, Lisa A. Cooper and Neil R. Powe, The Commonwealth Fund, July 2004

Patient Centered Medical Home

Place

Process

Person and Family Centered

Continuous

Comprehensive and Equitable

Team-Based and Collaborative

Coordinated and Integrated

Accessible

High Value

Shared Principles of Primary Care

Source: Patient Centered Primary Care Collaborative. 2017

Two Year Pilot

Hospitalizations – 33%

ER Utilization – 27%

Prescription Drugs – 19%

Health Case Costs (PMPM) – 26%

Patient Satisfaction

Physician Satisfaction

ROI – 10:1

Idaho Medical Home Pilot

Triple Aim

Better Health

Better Health Care

Lower Cost

The Quadruple Aim

Better Health

Better Health Care

Lower Cost

Joy of Practice

The State Healthcare Innovation Plan (SHIP) is a statewide plan to redesign Idaho’s healthcare delivery system, evolving from a volume-driven, fee for service system to a outcome-based system that achieves the triple aim of improved health, improved healthcare and lower costs for all Idahoans.

What is the SHIP?

$40M Grant (CMMI)

Four Years

Achieve Triple Aim: Better Health; Better Healthcare, Lower Costs

Projected Savings $89M/Three Years

ROI (197%) over Five Years

Idaho Healthcare Coalition (IHC) Model Testing Grant

Goal One: Transform Primary Care Practices to Patient-CenteredMedical Homes (PMCH)

Goal Two: Develop Virtual PCMH’s for Rural and Frontier Areas

Goal Three: Build out the PCMH Neighborhood (PC &BH Integration)

Goal Four: Develop Seven Regional Collaboratives to Oversee Delivery and Quality Integration

Goal Five: Build Statewide Data Gathering and Analytics System

Goal Six: Align Payment Mechanisms

Goal Seven: Reduce Healthcare Costs

Seven Idaho SHIP Goals

The Essential Nature of Primary Care1. Greater Access to Needed Services

2. Better Quality of Care

3. A Greater Focus on Prevention

4. Early Management of Health Problems

5. Cumulative Effect of Primary Care to more Appropriate Care

6. Reducing Unnecessary and Potentially Harmful Specialist Care

Source: Starfield B., Leiyu S., Mackinko J., Contribution of Primary Care to Health Systems and Health, (Milbank Quarterly, Vol. 83., No. 3, 2005) 457-501)

The Essential Nature of Primary Care (cont’d.)

7. Decreased Morbidity and Mortality

8. More Equitable Distribution of Health in Populations

9. Lower Cost of Care

10. Better Self-Reported Health

11. Primary Care Physicians achieve Better Outcomes than do Specialists at much Lower Costs

12. Increasing the Number of Specialists is Associated with Lower Quality, Increased Cost, Increased Morbidity, and Increased Mortality

Source: Starfield B., Leiyu S., Mackinko J., Contribution of Primary Care to Health Systems and Health, (Milbank Quarterly, Vol. 83., No. 3, 2005) 457-501)

Primary Care = Quality

Primary Care = Lower Cost

Increased Specialty Care = Lower Overall Quality

Increased Specialty Care = Higher Cost

Increased Generalist Care = Higher Quality

Increased Generalist Care = Lower Costs

The Medical Home Neighborhood Systems Level

Innovation in Delivery Systems Level

ACO

Accountable Care Organizations

Symphony of Care

165 Primary Care Practices (PCMH’s) over Three Years (825 PCP’s); 1.3M People (80%)

EHR/HIE Integration (PCMH/Neighborhood/Behavioral Health)

Build Seven Regional Collaboratives

75 Virtual PCMH’s (>550 CHW’s/CHEMS) / Telehealth

Data Analysis – Collecting, Analyzing, Reporting

Align Payment Mechanisms

IHC Model Testing Deliverables

Regional Collaborative

Patient Centered Medical Home (PCMH)

Patient Centered Medical Home Neighborhood

Idaho Healthcare Coalition (IHC) / SHIP

Vehicle and Model for Healthcare Transformation for Idaho

Built on Foundation of Primary Care and the Patient Centered Medical Home (PMCH)

Integrates and Coordinates the PCMH with Behavioral Health, Secondary Providers, Hospitals, and Other Members of Healthcare Team

Connects Public Health to Population Health Quality Metrics

Integrates Clinical and Claims Data

Aligns Payment Systems with Access and Outcomes

Idaho Healthcare Coalition (SHIP)

Primary Care is a Team Sport

Primary Care + Public Health = Population Health

Grant stops on February 1, 2019

Governors Executive Order for Idaho Healthcare Coalition extends through April 2019

Transition Workgroup

Council on Idaho Health and Healthcare

Drive Proactive Change• PCMH

• Medical Home Neighborhood

• Public Health / Population Health

• Data Analytics

• Quality Outcomes

• Payment Alignment

The Future of SHIP

“If you want to go fast, you go alone. If you want to go far, you go together”

African Proverb

www.fracturedhealthcare.comwww.amazon.com

Lessons Learned From Idaho Healthcare is Complicated!

“Coming Together is a beginning; Keeping together is progress; Working together is success”

Stay Focused

Be Persistent

Strengths• Family Medicine and

Primary Care• Public Health• People’s Passion and

Persistence• Medicaid• BH/PC Integration

Weaknesses• Data• Data Analytics• EMR’s• Payers – Commercial / Medicare• Culture Eats Strategy• Fatigue

Much Turmoil in Trying to Figure out Healthcare

Expense of Healthcare Killing the Country

Family Medicine and Primary Care is Fundamental to America’s Health Care Success

Behavioral Health and Primary Care

Triple Aim – Nation’s Strategy

Integration not Fragmentation

Teams Passing the Ball

SummaryHealth & Healthcare Transformation in the

United States: Where Does Idaho Fit In?

Leveraging Technology

Person-Centered Care

Partnerships and Collaboration

Complicated and Complex Work

Right Direction; Right Thing to Do

Trump/Administration – Wildcard

Summary Health & Healthcare Transformation in the United

States: Where Does Idaho Fit In?

“America will always do the right thing, after it

tries every other option!” Winston Churchill

“Never, never, never, give up.” Winston Churchill

Questions and Discussion