Bending the Cost Curve: The Role of Employers Karen Bray, PhD,
RN VP, Clinical Care Services, Optima Health November 4, 2011
Slide 2
Creating a Culture of Health Employer Group Focus
Member/Employee Focus Physician Focus
Slide 3
Challenges of Health Cost Management
Slide 4
Health Care Costs Health Care Costs are exploding In 2008
healthcare represented 17% of GDP Expected to reach 20% in 2017
Employers are looking for fast and effective cost-reduction
alternatives relative to health care premiums. Chronic care costs
are exploding. The numbers of people with diabetes is up by 50
percent since 1990. New technologies are expanding the scope and
reach of care. Heroic medicine is commonplace and very expensive.
Miracles happen routinely.
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Source: Milliman USA 2002 Health Cost Guidelines $0 $1,000
$2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000 $9,000 $10,000
Cost Per Person Per Year 0-1 2-6 7-18
19-2425-2930-3435-3940-4445-4950-5455-5960-64 Age Group Health care
costs by age group
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Health Care Spending per Capita, 2005 Source: OECD Health Data
2007 International perspective
Slide 7
Health status and outcomes Life Expectancy at Birth, 2004-5
Source: OECD Health Data 2007
Slide 8
Health status and outcomes Infant Mortality, 2004-5 Source:
OECD Health Data 2007
Slide 9
Financing Where the Health Care Dollar Went, 2003 Source:
Centers for Medicare & Medicaid Services, Office of the
Actuary, National Health Statistics Group
Slide 10
American health care "gets it right 54.9% of the time. McGlynn
EA, Asch SM, Adams J, et al. The quality of health care delivered
to adults in the United States. N Engl J Med 2003; 348(26):2635-45
(June 26).
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Other statistics: Patient non-compliance causes 125,000 deaths
annually in the U.S. Compliance Packaging: A Patient Education
Tool, D. Smith, American Pharmacy 50 percent of all prescriptions
filled are taken incorrectly. U.S. Chamber of Commerce $177 billion
is spent by the U.S. health care system every year to treat
medication error-related problems. Med Ad News, 2001
Slide 12
Variations in Medicare Spending Dartmouth Atlas Report Dramatic
variations in spending between 1992 and 2006 Miami increase by 5%
annually San Francisco increase by 2.4% annually Medicare savings
of $1.42 Trillion if all regions grew at SF rate Technology as the
culprit? Evidence from regions based on fee-for-service Differences
in organizational and local physician decision-making are key
Slide 13
Virginia Variations: Medicare spending per enrollee Adjusted
for inflation Range of 2.90% Richmond to 4.66% Winchester
Slide 14
End of Life Care Miami, last six months of life You will see
doctors (mostly specialists) 46 times You will spend > 6 days in
ICU, and have a 27% chance of dying in the ICU Portland, last six
months of life You will see doctors (mostly primary care) 18 times
You will spend 1 day in ICU, and have a 13% chance of dying in the
ICU You will likely die at home with hospice support 27% of
Medicare annual $327 M budget is for last year of life Dartmouth
Atlas Project, 2009
Slide 15
Rising Employee Health Costs The Employers Perspective The
Employers Perspective
Slide 16
Chronic Disease Conundrum 75%+ of health care dollars spent on
chronic conditions Diabetes Obesity Cardiovascular Disease Asthma
Most preventable through positive health habits Chronic disease
continues to rise at alarming rate
Slide 17
Wellness Program Conundrum Historically, wellness programs
achieved modest results Appeal to healthy employees who are already
committed to health Significant health improvements achieved when
employees with greatest health concerns Engaged & Motivated to
make healthy choices Carrot Approach Reward employees Reduce
insurance premiums
Slide 18
Engaging Leadership: The Cost of Doing Nothing Assumptions
Annual Employee Health Care Costs of $1,325,000 480 Employees 8%
Annual Cost Increase 33% of employees are obese 20% of employees
smoke
Slide 19
The Cost of Doing Nothing Wellsteps.com ROI calculator
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Reduce Obesity from 33% to 25% In an employee group of 480,
obesity decreases from 158 employees to 120 Wellsteps.com ROI
calculator
Slide 21
Obesity and Absenteeism Wellsteps.com ROI calculator
Slide 22
Reduce Tobacco Use from 20% to 15% In an employee group of 480,
tobacco use decreases from 96 to 72 Wellsteps.com ROI
calculator
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Smoking and Absenteeism Wellsteps.com ROI calculator
Slide 24
The Cost of Doing Nothing Wellsteps.com ROI calculator
Slide 25
Employer Group: Clinical Report
Slide 26
Health Risk Factors/Presence of Chronic Illness Identified for
Sample Group
Slide 27
Employer Group: Financial Report
Slide 28
The Employee Focus
Slide 29
Total Health: How Long, How Well We Live ~ 40% ~ 30% ~20% ~10%
Behavior: tobacco use, nutrition, Weight, MDD (movement deficit
disorder) Genetics Environment/public health Health Care Delivery
US Dpt of Health and Human Services, Public Health Service. Healthy
People 2010: National Health Promotion And Disease Prevention
Objectives.
Slide 30
Engagement Tactics Methods to Engagement: Trinkets and T-shirts
10-15% Merchandise Raffles (iPods, WII) 15-30% Cash Incentives
(under $100) 35-75% Healthcare Premium Reductions 50-80% Rewards to
Healthcare spending vehicle 50- 80%
Slide 31
The Physician Focus Primary Care Redesign
Slide 32
Challenges of Transformation Creating a Partnership Foundations
Trust Collaboration Mutual Respect Valuable Contributions Lessons
Learned It takes time It is not easy Worth it! Optima / SMG
Clinical Integration Activities Clinical Analytics &
Operational Coordination Population Profiles Monthly Meetings
Chronic Disease Population Management Diabetes Heart Failure
Incentive Programs P4P Program PCMH Incentive Program Outcomes
Measurement & Reporting PCMH Outcomes Study Measurement &
Reporting
Primary Care Is In Need of a Lifeline: Current Model is Not
Working Primary Care Is In Need of a Lifeline: Current Model is Not
Working Chronic Disease Burden is Growing - Increasing incidence of
disease + aging population U.S. healthcare Still Producing Marginal
Quality Escalating Healthcare Costs - Primary Care most cost
effective Medical Student Specialty Trends Stress of Overloaded
Primary Care Practices Compensation of PCP vs Specialists Patient
Care Growing Increasingly Uncoordinated
Slide 36
36 Patients Are Feeling the Effects Patients are Wanting more
control, more information, and more input Concerned about
escalating costs Unhappy with the increasingly uncoordinated care
Wanting better integration of care Patients want the system to be
Patient Centered
Slide 37
Care Team Capabilities and Optimized Technology Bringing it All
Together to Benefit the Patient Providers Organized as Care Teams,
Each Performing at the Highest Level of License Access to the Right
Provider at the Right Time Electronic Record and Registry
Capabilities to Coordinate Care for the Chronic Disease Patient
Improved Clinical Outcomes Fundamentally Redesigning the Delivery
of Primary Care
Slide 38
Primary Care Redesign Guiding Principles
Slide 39
Imperative to Transform Primary Care Redesign Today Alternative
Visit Considerations
Slide 40
The Evolution of Access
Slide 41
Slide 42
+
Slide 43
Before Same Day Appointments Claire is sick with a headache and
cough and its 5pm. She calls the doctors office and gets the After
Hours nurse who recommends calling her PCP in the morning. Not
feeling confident she can get an appointment, Claire goes to the
closest Urgent Care or Emergency Department instead.
Slide 44
The Need for Same Day Appointments The Issue: Access to primary
care has been proven to provide better quality at lower cost
However In some clinics, schedule nearly full at the start of the
day Many patients dont bother calling Here is an opportunity for
change.
Slide 45
Now, Claire has 2 options: Call tomorrow morning and see her
personal physician OR their partner. 2. Call the After Hours nurse
that night, and she can be scheduled for an 8 am appointment. After
Same Day Appointments Goal: Reduce Avoidable ED Visits, Patient
Satisfaction
Slide 46
Before Post-Hospital Discharge Follow-Up Protocol Drew, a 61
year old male is admitted with emphysema, cared for by a
hospitalist, and discharged with instructions to follow-up with his
PCP. Drew gets (expensive) new medicines, doesnt know what theyre
for, and is unsure about continuing his old medications without
talking to his PCP. Drew calls his PCP for a follow-up appointment
and is scheduled in his physicians first open slot 3 weeks from the
day he called. Relapse readmission.
Slide 47
Follow-Up after Hospital Discharge Why this is Important:
Vulnerable period 50% of patients do not know their medications at
the time of discharge 50% of patients do not understand their
discharge instructions F/u appointment with PCP not guaranteed
Poorly managed Transition = readmission Early follow up reduces
readmissions
Slide 48
After Hospital Discharge Follow-Up Protocol New Protocol: Drews
doctor/nurse is notified of discharge Daily staff huddles to
discuss patients like Drew Follow-up appointment scheduled within 7
days Medications reviewed/reconciled After-Visit Summary provided
The Result: Drew recovers and returns to work Goal: Reduce
Readmissions by Managing the Transition
Slide 49
Before MyHealth Champion James is a 62 year old with heart
failure who has been doing ok but has not been seen in months.
Hilga notes her husbands weight is up and calls the doctors office
but he is out that day and the nurse refers him to the ED. ED
doctor discovers 20 lbs weight gain, fluid in the lungs and James
is admitted to the hospital. failed outpatient management.
Slide 50
Introducing MyHealth Champion A Valuable Addition to the Care
Team: Embedded case manager Part of health team Continuous
relationship Manages transitions, proactive outreach Works to
coordinate care with different health providers Objective: Reduce
admissions, readmissions Reduce avoidable ED visits
Slide 51
New Protocol: Hilga calls when notes James weight is up
MyHealth Champion recommends same day appointment Arrives in office
and is found 20 lbs over his target weight Prompt intervention with
MD, medications adjusted MyHealth Champion coaches diet, daily
weights MyHealth Champion monitors between visits Goal: Prevent
Hospitalization Through Effective Outpatient Care After MyHealth
Champion
Slide 52
Todays World Bob Bob is a 56 year old construction worker
Diabetes for 10 years, on medications but is asymptomatic I feel
fine, Bob says, I dont need to see a doctor. In reality Bob is
about to get a wake-up call. High cholesterol, uncontrolled BP and
blood sugars 1 AM wakes up with chest pain Admitted to hospital
with heart attack Before Diabetes Registry
Slide 53
Patient MRN Last Known Office Visit Next Office Visit Last
HBA1C Value Last LDL ValueSystolicDiastolic Smoking StatusFoot Exam
StatusEye Exam Status 004274937/22/2009 11860NeverUnknown
501886722/1/2010 13054NeverNot DueOverdue or NULL 730584545/3/2010
7.2 13086NeverUnknown 500822585/13/2010 160110YesNot Due
504162077/19/2010 6.59910860NeverNot DueOverdue or NULL
402996117/23/2010 8.78116080YesNot Due 505898638/2/2010
7.68312070NeverNot Due 720997408/30/20102/28/20116.47412062NeverNot
DueOverdue or NULL 730183319/20/20102/24/20118.110813078NeverNot
DueOverdue or NULL 402501959/27/2010 9.87511068YesNot Due
5033114410/4/20102/7/20116.35710070YesNot Due 5069071010/27/2010
9.111711860QuitNot DueOverdue or NULL 7253167211/3/2010
7.312314260NeverNot DueOverdue or NULL
6248981012/20/20104/20/20116.5 12060NeverOverdue or NULL
4001933212/30/20102/21/20116.16013280YesOverdue or NULL
403571371/6/20115/9/20119.611215282NeverNot DueOverdue or NULL
632480671/13/20112/17/20118.45313470YesNot DueOverdue or NULL
402751161/19/20113/2/201110.8 14070YesNot Due
402801001/21/20113/14/20118.810816080NeverOverdue or NULLNot Due
503923791/24/20115/23/2011711713680NeverNot Due
631724361/27/20112/17/20115.111316464NeverOverdue or NULL
508100071/31/2011 5.810315080NeverNot Due
400693592/2/20112/23/20116.5 14690YesNot Due
402584762/3/20112/10/20117.114314070NeverNot DueOverdue or NULL
502231122/4/20112/24/20116.7122 70QuitOverdue or NULL 39987302
NeverUnknown
Slide 54
After Diabetes Registry New Protocol: Bob identified through
registry; no office visit in 6 months Secretary sets up an
appointment Labs before appointment indicate poor control MyHealth
Champion meets with patient, reviews diet and glucose testing, and
arranges between visit care Physician focuses on medication
management Bob is offered/invited to a group visit Goal: Improved
DM Outcomes, Prevent Complications
Slide 55
Results of Transformation The patient is the center of the care
team. Care is continuous. Care is accessible. Care is timely. Care
is comprehensive. Care is coordinated. Patients are engaged.
Providers are energized and enthusiastic. Transformation creates
and delivers excellence in Patient-Centered Primary Care.
PatientCentered Impact of Transformation
Slide 56
Creating an Effective Program within the Employer Group Engaged
Leadership Awareness Risk Identification Make it Easy, Make it Fun
Tracking and Monitoring Targeted to Identified Needs Effective
incentives/disincentives Company level reporting
Slide 57
Optimas Integrated Clinical Care Services We manage every
component ourselves Member-centric delivery of services Focused on
employer group types Health & Prevention Pharmacy Management
Medical Care Management Behavioral Health Management & EAP
Disease Management Quality Improvement Population identification
and stratification Predictive Modeling for future risk/service need
Collaboration with Providers
Slide 58
Easy to use Convenient All in one place
OptimaHealth.com/mylifemyplan
Slide 59
Sentara Healthcares Incentive- Based Health, Wellness &
Prevention Program
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Mission: Health Wellness Program Complete PHP 0-1 Risks 2-5
Risks
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Mission: Health Biometrics
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Mission: Health Disease Management Program Health Coach/Member
identifies opportunity for Disease/Condition Management Agrees to
participate and contacts program staff Agrees to participate and
contacts program staff Does not agree to participate No Incentive
Requirements 1. Active participation with Health Coach based on
assessment and stratification. 2. Completion of appropriate testing
and treatment plan as per program protocol. 3. Adherence to
medications as ordered by physician. Assigned to Health Coach $20
Incentive Adhere to requirements Does not adhere to requirements
Receive up to $220 incentive biannually to HSA 1 No incentive
received 1 Health Spending Account
Slide 63
Mission: Health 2011 PHP Screening Results Employees Covered by
Medical Plan 3% 4% 13% 61% 19%
Slide 64
Mission Health Modifiable Risk Factor Report Four year period
Clinical Variable Number of Members 5,356 members answering All
questions in all four years
Slide 65
Mission: Health Disease Management Comparison Medication
Possession Ratio Includes Total Mission: Health Population in
Disease Management
Slide 66
Mission: Health Total Costs PMPM By Claim Type Includes Total
Mission: Health Population in Wellness and Disease Management
Programs Members in Program All Three Years Claimants Over $70 K
Removed From Analysis
Slide 67
Mission: Health Disease Management Group PMPM Total Costs by
Claim Type Includes total Mission Health population in Disease
Management Members in Program All Three Years Claimants Over $70K
Excluded
Slide 68
Mission: Health Program Cost Actual versus Estimated Estimated
Costs for 2008 Based on Actual 2007 Costs Plus 8% Medical Trend
Estimated Costs for 2009 Based on Estimated 2008 Costs Plus 8%
Medical Trend Costs Include All Program Operations and Incentives
Paid Based on Cohort Members Continuously Enrolled in All 3 Periods
5.7% Increase Over Expected in 2008 12.3% Decrease Over Expected in
2009
Slide 69
Optima Health Easy to Use Better Health A Great Value
