Population Health Management: Building A Culture Of Wellness And Prevention

Author: Greg Wahlstrom

Good Afternoon everyone and welcome to The Healthcare Executive webinar series, "Population Health Management: Building a Culture of Wellness and Prevention". My name is Greg Wahlstrom and I will be your guide for today's discussion. We would like to specially thank Dr. Mandeep Mangat one of our panelist today.

For joining forces with The Healthcare Executive to bring this population health program to our healthcare executives globally. As we conclude today's webinar, you will be directed to a short survey, which we hope you will take the time to fill out. If any IT problems arise please visit support.anymeeting.com for further assistance. As we begin the presentation. Can you please mute your telephones until the question and answer portion of the event? On the left-hand side of the webinar platform screen is a text box to write a question to the presenters. If you have a general question, please insert your question into the text box. If you have a specific question for one of the presenters, please insert his or her name next to your question. Just as a reminder this webinar is being recorded.

We are truly honored to have so many of you from different parts of the world participating in today's discussion. As we move on to the next page, we will talk about today's program description. Population Health is a transformative factor in reducing chronic illness and key component of health care reform. It is dedicated to creating a fundamentally different culture and perspective focused on wellness and prevention. This program will provide new insights about topics related to chronic illness management, wellness and prevention, health promotion, and access to care. It will also provide an update on current and proposed models on population health management. Today, we will be covering: providing a current summary of healthcare challenges; The role of population health management in rewarding value over volume; Conducting community health needs assessment to address priority health needs: Assess the role of population health programs in reducing length of stay, readmissions and costs from hospital to home; Evaluate the role of shared decision making and patient experience in managing population health; Providing an understanding of the policies related to healthcare reform; Considering current and proposed models of care to improve quality, standardization, access, reducing costs and promoting accountability of care; Providing specific examples of successful population health programs; Discussing the application of evidence based medicine to improve health care; And, developing meaningful outcomes measures and collecting related data; As well as, supporting improvement in clinical outcomes through interoperable health information technology; Which models of care have demonstrated most potential in improving quality and reducing cost of care in specific healthcare settings; As well as, discussing your organizations use in use advanced analytics to drive population health management initiatives.

Now I would like to introduce today our subject matter experts. Today's moderator Greg Wahlstrom. Greg Wahlstrom is a result oriented senior healthcare executive with more than fifteen years of broad background in business, healthcare, and human services and has extensive operational and administrative expertise. He is currently the President and Chief Executive Officer of The Healthcare Executive leading organizational performance assessment in multiple program areas, followed up with customized c-suite healthcare training that speaks to identified needs. Greg has delivered focused programming around key elements to achieve success, based upon best practices and emerging best practices that show promise of improving health care organizations nationally and internationally.

Population Health Management: Building A Culture Of Wellness And Prevention

He has led webinars, and face-to-face seminars for thousands of healthcare administrators and executives through the American College of Healthcare Executives. Prior to The Healthcare Executive, Greg worked as an Assistant Administrator, Director of Social Services and a Behavioral Health Care Manager. Greg received a Master's degree in Business Administration and Healthcare Management and a Bachelor's degree in Business administration from the University of Phoenix. He has also completed studies abroad at Shanghai University in Shanghai, China. He is a member of the American College of Healthcare Executives. Greg is also a current immediate Past Chairman of the Healthcare Executive Education Committee for the Central Illinois Chapter of ACHE.

Our next presenter. Dr. Mandeep Mangat, MD, MPH, Senior Administration Population Health Management and Clinical Integration Bayada Home Health Care. Mandeep K. Mangat, MD, MPH is a Senior Administrator of Population Health Management at Bayada Home Health Practice. She directs the ongoing development, implementation and coordination of population health initiatives aimed at enhancing quality of patient care and clinical outcomes at a system level.

Prior to joining the position in 2014, she worked as a Physician. Public Health Professional and Director Of General Medicine Department in acute care settings. She has over 14 years of extensive healthcare experience in hospital medicine, home health, clinical operations, population health and operational efficiency improvement in both national and international settings. Her interests include outcomes management, results driven continuous improvement and multilevel determinants of population health.

She received her medical degree (MD) from Saint Petersburg Medical Academy. Master's degree in Public Health (MPH) degree with a focus in Healthcare Administration from West Chester University and Lean Six Sigma Healthcare Process Improvement Master's Certification (LSS) from Villanova University. Our next presenter. Dr. Leslie Mathews, MD, MS, EMBA, FACHE Chair, Healthcare Management Program Franklin University Dr. Mathew has thirty-five years' experience in the healthcare industry, having worked internationally over the years. After completing his MD in 1979, he specialized in the medical diagnostic area and has pioneered and chaired Departments of Pathology and Laboratory Medicine in India and the Middle East, always involved with teaching and patient services in the different positions he has held at academic medical centers over the past 3 decades.

He has been awarded numerous Teaching Excellence Awards in recent years. Besides earning a Master's in Biotechnology Enterprise from Johns Hopkins University, he also had the privilege of completing the Executive MBA program from The Fisher College of Business while working as Administrative Director of Operations at The Ohio State University Medical Center, Columbus, Ohio. Dr.

Mathew has taught at both undergraduate and graduate levels in Healthcare and Business, in both non-profit and for-profit institutions. Most recently, he worked as a Dean of Education for a higher education group that had 52 schools with mainly Allied Health Programs around the United States. Currently the Program Chair for the Allied Healthcare Management and Healthcare Management Programs at Franklin University. College of Health and Public Administration, Columbus, Ohio. He has been an active member of ACHE, and earned the distinction of being a Fellow of the college.

And our final presenter this afternoon. Shawn Zierke, MPH Executive Director ICPHA Iowa Counties Public Health Association Shawn Zierke is a Public Health Policy and Administration healthcare executive with more than 10 years of experience, blending organizational management, understanding healthcare practice, and advocacy for Iowa's aging and disability communities. Current projects and volunteer activities include work with policy related to public health, rural health, population health management, state level legislative advocacy for aging and disabilities communities and developed tool-kit to increase collaborations between county public health and Accountable Care Organizations (ACOs). Developed and delivered 67 customized-walk tool kits for Iowa's county public health departments to collaborate with their regional Medicare ACO to achieve quality measures and earn shared savings incentives. Shawn received a 2014 Health Sciences Research Week Poster Competition - (t-4) Translational Research Award for presenting research of the highest caliber during the 2014 Health Sciences Research Week Post Session - "Reducing Unplanned 30-Day Hospital Re-Admissions Among Patients with Pneumonia and Congestive Heart Failure over age 65". Shawn received her Master' in Public Health Policy from the University of Iowa College of Public Health, and is currently completing her Master's in Business Administration in Social Entrepreneurship.

She is currently the Executive Director for Iowa Counties Public Health Association. Representing Local Public Health Administration from 101 public health departments across the state of Iowa. Now we would like to interject a quick poll question. And that is: how many in the audience are international attendees versus domestic? So the results are 98 percent domestic, and 2 percent international. So I will just close the poll. Ok so we can see primarily most of our attendees are joining us here in the states. I am going to go ahead a pass the floor over to Dr.

Mandeep Mangat. Dr. Mandeep! Good Afternoon.

Greg and thank you for the introduction. Welcome to all of you who are reading or listening to the webinar. I have been asked to discuss some of the key healthcare challenges and role of population health management in improving health outcomes. First of all, the United States spends roughly twice as much on healthcare as other advanced countries do.

Yet the outcomes are inferior in many respects. There is a shifting demographic for patients and the workforce. There is also drive towards cost efficiency, transition to value-based reimbursement and increasing demand for cost and quality data sent to MD. This also increase focus on physician leadership, alignment and engagement and reducing variation in care. There is need for clinical integration and care coordination and a growing demand for patient and family engagement. Now the biggest barriers to population health management are the segmentation and healthcare delivery, poor communication between inpatient and outpatient providers. Miss-aligned financial incentives and lack of management care knowledge.

And also insufficient use of health information technology. Healthcare reform has not solved the major problems of our system, in respect to, quality, access and cost. To do that, we will need to achieve the Triple Aim. And, find a way to manage population health efficiently. Population health management requires an organized system of care. It has been defined as an approach that focuses on the health outcomes of individuals in a group and the distribution of outcomes in that group. Most people don't think about the ------ if they have one. Most are not under treatment or see their primary care provider regularly.

But for all people the environment in which they live their race, culture, language skills, lifestyles and behavior are core determinants of their individual health. These non-medical determinants of health, which are far greater impact than medical care are not being addressed properly. The fee-for-service payments system that rewards provider’s volume of services has implicated in the high cost of healthcare in United States. Fee-for-service incentives physicians for far more services rather than help patients get well or prevent them from getting sick. Physicians usually have no financial incentive to communicate online or care for them at home.

Over the past 20 years or so, approaches such as: pay-for-performance and disease management have had a very limited effect on quality improvement. More promising models including patient centered medical home and clinical care organizations have emerged in the past few years. The industry at this point is emits of rapidly accelerating from fee-for-service to various forms of fee-for value. And, find that they are evident around us. Health insurer Aetna is paying incentives to practices that have a huge recognition as patient-centered medical homes. And is working with provider groups and health systems to create Accountable Care Organizations.

One of the nation’s largest insurers Well Point has tied a third of its commercial reimbursement to fee-for-quality programs. Medicare shared savings program are on-boarding ACOs that create savings and meet quality goals. As we transition to new delivery care models. Instead of basing our decisions on how the clinicians and organizations can produce costly durable services we need to maintain or improve patient’s health and deliver good outcomes. Whether an organization is identifying the population and care gap, identifying risks, engaging the patients with interventions, managing care or measuring outcomes and integrated technology foundation is required to decrease cost and improve clinical quality. Achieving results involves conducting gap analysis of current technologies, identifying vendors with necessary solutions to fill those gaps and implementing the solutions successfully. Now there are automation opportunities in each of the care team process steps listed on the slide.

For instance, in terms of managing care and targeting the right patients we can conduct assessments using office visits or over the phone using --- or other tools that may or may not be integrated in EMR. Or we can send all patients online to the online risk assessment tools the results can be used for individual and population health management. Patients who are well today maybe sick tomorrow. The front end of infrastructure for population health management is predictive modeling, which forecasts which patients are likely to get sick or sicker in the near term.

It depends on computer algorithms that can recognize problems within data. Very few organizations do predictive modeling at this point because most of don't have enterprise data warehouses all to needed for this approach. But all that is expected to change under new payment models that puts them a financial risk. The term "Community Health Needs Assessment" The first process is community engagement, collection, analysis, identification of data on health outcomes and health determinants. Identification of health disparities and identification of resources that can be used to address priority needs. The ACA requires non-profit hospitals and health systems to conduct assessments every three years and then develop community health improvement plans. Many public health departments already perform needs assessments as part of their accreditation process. All of this shows the siege for greater collaboration among hospitals, public health departments and other community organizations.

I think that affordable care act is serving as a catalyst to bring together the true vectors because the true focus of ACA is so much improving population health. We have gone from the time when most of diseases were acute to know where most are chronic. The physicians don't have the tools to go beyond the clinic walls. The ultimate goal is that the hospitals role will be reduced because people will be cared for more on the outside. It’s less expensive and easier for two or more hospitals to create a needs assessment together likely in concert with local public health departments. At first that would typically involve tackling some of the more easily identified community health problems such as: smoking, obesity, prevention, or prescription Opioid use.

I think through this process the organizations learn how important to have all parties at the table. When the various entities have same prioritized issues they may use same qualitative and quantitative data. A common set of health status metrics can facilitate these issues across population, promote collaboration between organizations conducting assessments. It can also assist in establishing a shared understanding of the factors that influence population health.

Centers for Disease Control and Prevention Community Health Assessment report on this slide is meant to be a time saving resource for identifying and analyzing data for community’s health needs. This report provides a reference list of most frequently recommended health outcomes and determinants to valid indicators available at the Metro College in Statistical Area County or sub-county level. So, what you see on this slide are some useful resources for community health needs assessment including CHNA tool, US Census Bureau website, the CDC Center and County Health Ranking. The issue of unnecessary hospital re-admission is now front and center and the national conversation of about quality of healthcare. Hence, to Medicare’s re-admission reduction program hospitals are working hard to bring their re-admission rates down. Readmission affects nearly one fifth of Medicare patients discharged from the hospital. CMS will fine hospitals with high re-admission rates at an estimated total of 428 million dollars in fiscal year 2015.

The increase in overall --- the amount and the number of hospitals is partly driven by the additional conditions: total hip, total knee replacement and chronic obstructive pulmonary disease to the program. In addition to heart attack, heart failure, pneumonia 30-day readmission rate. In fiscal year 2017, CMS will add Coronary Artery Bypass Grafting Cabbages re-admissions to the program. It’s probably a good idea for hospital executives to start focusing on their performance on this measure right away.

As it is most likely being counted towards fiscal year 2017 payments and will mean higher penalties for many when it’s all said and done. The imminent cause of re-admission is usually a rapid worsening in patients’ condition but it can be attributed to systemic failure of a fragmented healthcare system. That's too often leads discharge patients confused about how to care for themselves at home. And unable to follow instructions and get the necessary follow up care. A list of innovations to improve care transitions out of hospitals are now speaking through the hospital sector. There are several new government incentives and arise awareness to improve patient safety which are forcing hospitals to place an increased emphasis on discharge planning and post-acute care.

Like I mentioned before, beginning in fiscal year 2015 CMS will scrutinize re-admission for acute exacerbation of COPD, elective total hip and total knee arthroplasty. So the government sponsors partnerships for patients. CMS is paying community based organizations a set amount per discharge for managing Medicare beneficiaries at a high risk for re-admission. Under CMS bundling demonstration which started in April 2013 providers need to choose one of the four options on this slide model one through four.

Medicare shared savings program for Accountable Care Organizations which began in 2012. Also have the -- incentives to collect re-admission in order to generate shared savings. Hospitals should consider the use of innovative technology in patient portals to improve communication between patients and clinicians to improve the quality of care and reduce readmission of patients with chronic diseases. Academic experts have identified several of their approaches that can reduce re-admissions. Institute for Healthcare Improvement are Italian models advices focusing on the patients journey overtime across settings in a past assessment of post-discharge needs. Coleman Care Transitions Intervention model emphasizes the use of transition coach to visit the patient in the hospital and at home and make follow up phone calls to help patients with self-management skills. The Naylor Transitional Care model involves care coordination by transitional care nurse that has advanced practice training to visit the patient daily during his or her hospital stay.

Visit the patient at home during the first 24 hours after discharge and then weekly during the first month. There are other resources that your organization can leverage from including the SMH program of Society of Hospital Medicine. In terms of predictive analytics, a number of vendors offer application designed to predict which patient are likely to be re-admitted to the hospital. Patients and clinicians have different expertise when it comes to making consequential clinical decisions.

While clinicians know information about disease, tests and treatment, patients know information about their body, there situation, and their goals for life. Agency for Healthcare Research and quality recommends the share approach which is basically a five step process for shared decision making. And it includes exploring and comparing the benefits, harms, and -- so each option though meaningful dialogue what matters most to the patient.

Decision needs such as: education, literature, videos or web-based tools are designed to help patients prepare for these conversations. A comprehensive review by Cochrane Collaboration found that patients needing physician aide often choose to pursue less invasive surgery more often and finding that is caught attention of those hoping to reduce over-use and miss-use of resources. Your organization can also utilize --, shared decision making national resource center decision aide. Most of --- decision aides are related to chronic disease care and are designed to be used as conversational props during the office visit. For example, the diabetes medication choice decision aid you can see on the slide helps patients and their providers choose among 6 medications commonly used to treat.

But the organization will both with care teams that enable clinicians to operate at the top of their licenses. For example, many high performing group trained medical assistants to act as health coaches for patients with chronic diseases. The organizations will apply analytic and automation applications to steer population. For example, PBR Health a 180 doctor multi-specialty group in Wisconsin uses a program linked to its registry which triggers automated messaging to the patient with care gaps in areas of diabetes and hypertension. Patients who were contacted through this technology made appointments the rate of non-contacted patients. Some organizations will adopt the Lean approach to improve their work processes.

For example, care teams trained in Lean principles can map out the workflow of a patients with it. Identify wait times do a root cause analysis counter measure and reassess with data. The current trend of tele-health and remote patient monitoring will continue to grow.

Patients will use mobile apps to communicate with providers and keep them informed about their health and to improve healthy behavior. In the end, a successful organization will be the best ones with best data and the ability to use that data to drive their outcomes. To wrap up my presentation, I would like to take an opportunity to introduce a poll questions.

Do you think your organization has grasped the basics of Population Health? So we see that majority of the participants think that their organization has grasped the basics of Population Health marginally. Its not surprising to see that result. We are going to go ahead and close the poll. Okay and I just wanted to go ahead and ask a couple quick questions related to your presentation. So, when implementing population health initiatives healthcare leaders need to consider where resources should be allocated. What would you consider to be the most essential area to consider in the spectrum of Population Health? So, with the new healthcare delivery model there are new demands and care systems that will require leaders to prioritize their expertise and develop diverse collaborations and co-leaderships between other organizations and within their own organizations. I think a strong institutional culture and supportive infrastructure are essential to the success of population health management. Organizations would need three foundational components to integrate population health management into their organizational structure.

Including a capable and qualified workforce that is trained in community and population health principles. And, apply change management keeping in mind that in population health world end users include providers and consumers, patients and members. The organization will also need strong health information technology platform and translatable data to track health trends for targeting -- populations. Finally, they would need organizational capacity, which would include strong backing from senior hospital leaderships, clinician engagement, formalize community partnerships and other aligned resources. Thanks for sharing. One last question, before Dr.

Mathew presents. You did a wonderful job explaining Community Health Needs Assessment can you share with the audience this idea. As healthcare leaders we often refer to the Community Health Needs Assessment to identify and understand the leading health problems. How would you use this data to create programs to improve these health concerns? So, the major goal of community health needs assessment is to use the data collected through the process to create a climate for change that leads to improvement in the health of the community. The process allows communities and the hospital and organizations to understand what the data says about the health status of their community. The process also gives communities and other organizations to discover what their residence would like to see changed. Which groups, organizations or individuals are already trying to address key health issues and what barriers hinder the community’s ability to achieve optimal health.

By providing all this data which documents the community needs. Community Health Needs Assessment kind of allow us to build or enhance partnerships and collations. Community -- involvement has especially been important over the past few years. As the communities began to focus more on social determinants of health and on creation of an environment so that people can be healthy.

Examples of the programs that have focused on creating healthy environments includes: eliminating food deserts and providing more opportunities for appropriate physical activities for adding walking trails and reaching joint use agreements. These types of changes don't focus on individuals with specific health problem rather they target the health of overall community and that is population health. Great! Thanks for sharing those key insights. Now I would like to introduce our next panelist Dr. Leslie Mathew.

Good Afternoon Leslie! Good Afternoon Greg and everyone we have had good presentation from Dr. Mandeep and telling us more about the issues and understanding population health management, as well as, some of the initiatives there. I am going to step back a little bit and look at a bigger picture before we go onto our next presenter. So, I want to start with a pole rather than end with one. Just to get a little sense of how many of you in the audience are actually working in Population Health Management at this time. I going to go ahead and pull up the poll. Give you 20 or 30 seconds to answer that.

Well thank you for holding. I think most of us have voted. Almost looks like a tie breaker at 50 percent each but it is. Working in Population Health Management is 46 percent and no 52 percent. So I guess very slight majority for those not working in Population Health Management. And, I just ask the question, so that I don't get to basic in what I am going to share with you in the bigger picture behind Population Health Management.

Now, to just go back and think about the possibilities related to healthcare reform which is very basic. Here is a cycle of events. Sometimes a vicious cycle of events.

Which a most of are familiar with. Where we have a consumer who cannot afford the doctor and delays care and as a result this compounds progression with disease and finally goes to Emergency Room. When the limits are reached and then of course the consumer cannot pay and the providers shift the cost to insurance, the insurance shift the cost to the consumer and then you find the consumer drops the policy due to high price and now is uninsured. Now all of us know in healthcare reform that the whole idea was increasing access, and one of the lengths to the stewarts increasing access lowering costs of course, but as it pans out in the last few years we can easily see, that the cost has not been contained as was originally thought of. So, I fear of and that we can already see that this cycle is actually repeating itself. We thought it was a thing of the past where we would not get this cycle repeating itself but as I can show you a few slides later there are reasons for people to start dropping out some of these newer possibilities that they have through healthcare reform, the healthcare insurance exchanges and employer passing on more burden back to the employee and so forth.

So, we can see clearly that this cycle is still kind of operational which is one of the sad parts of reform not having really taken us all the way to the gold post as it were. So, we are short of reaching that goal of course all of us know that. We will move to the next slide, to give you something that is very basic again and I think all of us realize that Dr. Mandeep referenced to that, the burden of chronic disease is really a huge problem that is unfortunately we have allowed that to grow and become a major issue for us and I just wanted to give some thoughts here. To make us more aware, that chronic disease is responsible for more than half of all deaths in the world. And it is projected to account for two thirds of all deaths globally in the next 25 years. This progression of chronic disease is occurring despite the fact that these diseases are largely preventable.

While the chronic disease epidemic will initially concentrate in developing countries, globalization has grossly increased in chronic disease to be even greater in emerging economy. Countries that be --- towards WIC, Brazil, China, Russia and India, Brit countries or emerging economies currently lose more than 20 million preventive life years annually to chronic disease. And, that number is expected to grow to 65 percent by 2030. This poses significant threat to the vitality of a highly interdependent global eco system.

Which can threaten the sustainability of already burdened Social Security’s systems in industrialized countries or societies. Well I put this slide to talk a little graph where you can see yellow growing is the chronic disease. And I have given four reasons why organizations would have a clear interest in preventing chronic disease for these four reasons and I will elaborate a little bit on that as we go forward. In the US alone people with chronic disease account for more than 75 percent of the nation’s 2 trillion-dollar medical expense. Whether healthcare is financed by employers, individuals or social programs the impact of chronic disease is placing an increasing burden on health systems, taxes and cost of coverage, which is an increasing burden on organizations and their employees.

The second point there is even more significant that the productivity losses associated with workers with chronic diseases are as much as 400 percent more than the cost of treating chronic disease. Losses in productivity include: disability, unplanned absences, reduced workplace effectiveness, increase accidents and negative impacts on work quality or customer service. The most costliest conditions in healthcare and healthcare risk factors relates to productivity are different from those when considering only the costs of treating the disease. Depression, fatigue, and sleeping problems conditions or lists that are often cobalted with chronic diseases. They have a largest impact on productivity as with healthcare costs more risk factors multiply losses in productivity. The third point that I had there is that the workplace wellness efforts can possibly impact human capital investments.

And a quick step here is that organizations invest an average of $290 US dollars in labor costs to generate $1000 US dollars in revenue. By helping employees work longer and have more productive life organizations can protect this asset in the face of growing labor shortages globally. Organization that shows it values its workers is more likely to attract, retain and motivate employees. Leading organizations have utilized prevention and wellness programs to demonstrate the value they place on their workers. And, lastly we find that sustainability is threatened by the epidemic of chronic disease. The epidemic is really a product of both environment and behavior and social economics that is equally prevalent and preventable as the issue of global warming, infectious diseases, poverty, terrorism, unsanitary water and basic infrastructure.

In fact, many of those issues are inter-twined with the issue of chronic disease. As the economic burden of chronic disease grows it could crowd up monies needed to prove those other critical issues and as well to meet other basic needs such as education and infrastructure in both industrialized and emerging economies. So these four critical issues healthcare costs, productivity costs, human capital investment and sustainability can drive the focus on wellness in organization and this really needs to show up on the radar all the time. So in conclusion, on this slide we really have to move from illness to wellness is well recognized now. Businesses will have to invest wellness there is really no choice and as somebody says, "Its not philanthropy is enlightened self-interest". So, the burden of chronic disease is what I wanted to press upon is really the biggest burden that is holding us back and not an easy path out of which ah a generation at least. So let’s go onto the next slide. Which really is just trying to give you a little background on how we arrived at these various models.

If you look at our globe, there are about 200 countries on our planet and each country devises its own set of arrangements for meeting the Triple Aim that Dr. Mandeep talked about. But we don't have to study 200 different systems to get a picture of how other countries manage healthcare. For all of the local variations the healthcare system tends to follow general patterns and I am giving you four basic models. You know its academic but I think it is really its summarizing how to world today functions and course you will see where the US fits in.

The first model you have on your left on the screen is a Beveridge Model. Named after a daring social reformer in Britain who designed the national health service in the UK. Many but not all hospitals and clinics are owned by the government there. In this system healthcare is provided and financed by the government through tax payments just like the police force or the public library. Some doctors are government employees but there are also private doctors who collect their fee from the government. In Britain, you will never get a doctor’s bill. Most of us would like to live in the UK.

These systems tend to have low cost per capita because the government as the sole payor controls what doctors can do and what they can charge. Now countries, using the Beveridge plan or variations on it include its birth place, Great Britain, Spain, most of Scandinavia as you can see there and New Zealand. One country that I did not put there was Hong Kong. Small country but still has its own Beveridge style healthcare because the population simple refused to give it up when the Chinese took over that former British colony in 1997 and the last one on that model is Cuba represents the extreme application of the Beveridge approach it is probably the world most purist example of total government control. Moving onto the next model the Bismarck Model all of us may know that that named for the Prussian Chancellor Otto von Bismarck who invented the welfare system as part of the unification of Germany in the 19 century. Despite its European heritage, this system of providing healthcare would look fairly familiar to Americans. It uses an insurance system the insurers called "sickness funds" usually financed jointly by employers and employees through payroll deduction.

Unlike the U.S. Insurance industry, though, they Bismarck-type health insurance plans have to cover everybody, and they don't have to make a profit. Doctors and hospitals tend to be private in Bismarck countries: Japan has more private hospitals than the US. Although this is a multi-payer model- Germany has about 240 different funds tight regulation gives government much of the cost-control clout that the single payer Beveridge Model provides. And this Bismarck Model is found as we can see on the map Germany, France, Belgium, Netherlands, Switzerland and to a degree Latin America as well. We will move onto the next model which is "The National Health Insurance Model". And this system really has elements of both Beveridge and Bismarck. It uses private-sector providers, but payments come from a government-run insurance program that every citizen pay into.

Since there's no need for marketing, no financial motive to deny claims and no profit, these universal insurance programs tend to be cheaper and much simpler administratively than American-style for- profit insurance. The single payer tends to have considerable market power to negotiated such low prices from pharmaceutical companies that Americans have spurned their own drug stores to buy pills north of the boarder. National Health Insurance plans also control costs by limiting the medical services they will pay for, or by making patients wait to be treated as many of you known in Canada there are long waiting list for surgical example.

So that is how they control. The classic National Insurance Model is found mainly Canada but for new industrialized countries like Twain and South Korea have also adopted this model. And lastly, I will come to "Out-of-Pocket Model" that I must say that only the developed, industrialized countries perhaps about 40 of the world's 200 countries have established health care systems. Most of the nations on the planet are too poor and too disorganized to provide any kind of mass medical care. The basic rule is such countries is that the rich get medical care; the poor stay sick or die. In rural regions of Africa, India, China and South America, hundreds of millions of people go their whole lives without ever seeing a doctor.

They may have access, though, to a village healer using home-brewed remedies that may or not be effective against disease. In the poor world, patients can sometimes scratch together enough money to pay a doctor bill, otherwise, they pay in potatoes or goat's milk or child care or whatever else they may have to give. If they have nothing, they don't get medical care. Now I said all of this to say these four models should be fairly easy for Americans to understand because we have elements of all of them in our fragmented national health care apparatus.

When is comes to treating veterans we're Britain or Cuba. For Americans over the age of 65 on Medicare, we're Canada. For working Americans who get insurance on the job, we're Germany. And, for the 15 percent of the population who have no health insurance, the United States is Cambodia or Burkina Faso or rural India, or any of those countries that do not have a model like we do. So, with access to a doctor available if you can pay the bill out-of-pocket at the time of treatment or if your're sick enough to be admitted to the emergency ward at the public hospital. The United States is unlike every other country because it maintains so many separate systems for separate classes of people.

All of the other countries have settled on one model for everybody. This is much simpler than the US system; it's fairer and cheaper, too. So just a little time to explain these two slides to you and we will move onto the next one. Which is really talking more again about the basic um one of the um that Dr. Mandeep was the Accountable Care Organization. And, if you look at the Accountable Care Organization basically the whole structure is divided into two parts. If you ignore the complexity of the federal definition the concept behind the ACO has been practiced actually for many years by integrated delivery networks such an Intermountain Healthcare and Kaiser Permanente. And, so accountable healthcare really boils down to simple consultation of these suiting’s.

One managing the fixed price contracts for the treatment and management of individual patient health in contrast the fee-for-service, time and materials, and contracts. And the second part, is the applying the patient’s specific concept of balancing cost of care which quality of care for large populations of patients. So, this is where the diagram that is here really we are going to focus on the next slide on just the outer circle which is really what Population Health Management is really all about; and, that is optimizing the health of large populations.

And, the next slide is going to a bit of a busy slide. I am not going to go through every one of them in detail. But basically, it shows us in order to get that optimization of the data that is required for effective population health management. There are about 12 criteria that has been listed as required in an organization in order to be able to achieve the goals of that Population Health Management has. Now, many organizations are only at a starting point for this some a little along but very few have reached and achieve all of those 12 criteria. So I just wanted to mention that the future of population health medicine really depends on going forward all these criteria and you can see them stretched over a five-year period. And, the first six of them are those that we will call them foundational and very important that we start with that and so slowly develop the others as the --- gets closed. For example, the first one I will talk about precise patient registry, building accurate population registry we all know is a foundation of effective population health management.

Precise registries are gatekeepers to accuracy. Without precise definition of the population of concern. First, everything else in the strategy suffers.

Traditionally, population cohorts have been defined using billing data specifically ICD-9 Code. However, relying solely the billing data to define the patients in these cohorts means organizations will likely miss thirty to forty percent of the patients that would be included. In a value-based fix based contracting model that level of inaccuracy will be financially devastating to the ACO. And, so the definition of population must be clinically informed. Billing codes represent the first step, but registries must take into account data for the lab results, functional status measurements, diagnostic imaging results, medication, claims data, procedure codes, clinical observations, vital signs, etc.

Now, all of this data extracted and filtered from different data sources in the organizations ecosystems and bound together in a enterprise data warehouse. That's what would be required to build an accurate profile of a disease or patient --. So that will just be the first one. And, as I said I am not going to get into too many of them. But, this gives you an idea of what we face.

All these things need to be done in order to get population health management achieving its goals. I'll just move on as you have obviously looked at them. And can read them out of course.

The precise provider attribution is one thing that is important. Precise numerators, clinical cost in metrics, then you have the clinical practice guidelines required and risk management outreach. Now if I go to the next slide, we will find that I put on something that which kind of indicates something like 80/20 rules that is you will find in the no go back. You will find that the first 6 criteria really is where we are going to spend 80 percent of our resources the first 2 to 3 years. And, then it would normally go a you know less costs more than there where as we would be spending more and allocating more resources for the criteria ---.

Over this five-year timeline suggested. So, I'll leave that thought with you and I am sure there is a lot more exploring that you can do and in fact I there is a whitepaper that I reference to by Mr. Dale Sanders who is the Senior Vice President of Health Catalyst which really -- in great detail and I think it's a valuable resource to reference to. As we move on to the next slide, and this is just to tell you that there have been many proposals and many plans have been put forward in order to remedy so of these ills or problems that we face with the Affordable Care Act. There has been private sector initiative, public sector initiatives, some of us are very familiar with value-based purchasing from CMS or the Premiere Hospital Quality Incentive Demonstration and I think Dr.

Mandeep referred to that. Another CMS demonstration was Physician Group Practice demonstration. I am just going to focus on one of them on this slide here. Universal Exchange Plan produced or put forward by the Manhattan Institute For Policy Research and we all notice that after the ACA will especially drive up the cost of private health insurance that individual's purchase directly. The law will dramatically expand a Medicaid program to the poorest health outcomes of any health insurance system industrialized world. And, the ACA despite spending over 2 trillion over the next decade will lead 23 million lawful U.S. Residents without health insurance.

According to estimates by the Congressional Budget Office. So, this goes back to this initial circle that I should you were in spite of all this it all looks like we are gonna have a good number according to this estimate by -- 23 million U.S. Residents without health insurance at the end of all the efforts of ACO after 10 years.

So often many as you now provenience and openness of this current system that we have been evolving through and there have been a lot of lobbies for repealing the law and replacing it. This particular one is really more of accommodation of a repeal and replace the one put forth by the Manhattan Institute for Policy Research. Because their concern is that we do not want to disrupt the healthcare system while there is a repeal in order to put the U.S. On another path. So, they have put this forward with this consideration might have adopted the Universal Exchange Plan which seeks to substantially repair both sets of the healthcare policy problems. Those caused by the ACA and those that predated which are still the difficult challenging ones.

So, that's basically where most of you can see up on the slide there as you can find it repeals the ACA, individual, --, and all of that expect the Cadillac tax. Which of course is again a disputed tax which is to be implemented from 2018 onward. Many are already getting notice about it, including employers and therefore this one of course --- Cadillac tax. It also frees exchanges from costly federal regulations and come back to hospital monopoly it also migrates Medicare enrollees and future retirees onto these reformed exchanges.

So, there some figures here about the deficit of 30-year deficit reduction of 8 trillion and 30-year revenue reduction 2.5 trillion is what is estimated by this plan and it makes the Medicare -- soften and reduces private sector premium. So these are some of the benefits from this plan it also says that the Medicaid population it provides better access to 98 percent and medical productivity by --- percent of this desirable and by 2025 it increases coverage by 12.1 Million above what is estimated by the Affordable Care Act. This is just one proposed model and so that get a taste of what it is. Okay and I think at this point I will pass it over to our host Greg Wahlstrom. Yes! Wow! Thank you Dr. Mathews for sharing a wealth of knowledge especially with population health and health care reform. Before we pass the floor over to our final presenter this afternoon. I would like to inject a couple quick questions.

Dr. Mathew as you mentioned about socio-economic status and the inability to pay for medical care in relation to the Affordable Care Act do you think health care reform has positioned patients with less access to affordable healthcare? Well that is an interesting question because I am sure have two sides to that debate. But I think as we years gone beyond 2015 you’re definitely seeing as I mentioned in that initial circle that some are going dropping off rather than getting on. And, therefore I think in a sense overtime although initially of course we had whatever number of million registered through the insurance exchanges.

I think over time you are going to find the cost of private insurance particularly is going to go up its only going up. Employers are passing much of the increase back to the employees and consumers. We are definitely find more people dropping off that is what I said initially the cycle seems to be reinforced even with 10 years of the Affordable Care Act. So my answer really would be that we are going to be giving less access finally in terms of global and theirs is another aspect to that is that the accessibility of physicians was still not adequate in the primary rural areas you will find is going to therefore even less.

So if you take that factor in physician access is going to actually to be less because we care not churning out medical doctors as much as what will be required for these increased volume of 18 or 20 or 30 million coming into the insurance exchanges. So my answer would be really no think we are actually ultimately going to provide less access. Okay, I concur I do believe though that the implementation of the Affordable Care Act has really caused many uninsured and under insured American's to obtain access which inevitably will demonstrate a healthier impact on population health. So, thanks for sharing that. In respect, to public health could you tell us how can you quality measure be improved from its current state? In respect to Public Health.

I guess that is a broad question but you know I both my co-speakers are public health experts and I could ask them to chirp in if they need to but I am going to make it very simple to say that I think there has got to be more awareness and education built in and about many of the plan that started out even before the ACA quality was a very clear focus in some organizations and what they did not do at that time was bringing in the cost factors. So, you talk up Public Health measures again there are many initiatives but the cost factors when in fact factored together in with that so I think the ---- force of known to combine the quality and the cost to be considered at the same time. And, I think that awareness building that into our systems even Public Health would be a fundamentally important thing. Of course the other thing is, quality measures when you say measures a lot of things that I have done that are not measurable that and if they are not measurable they didn't happen. So, I think that is the other thing that in the Public Health arena which I would like Shawn or Dr. Mandeep to come in and comment on also is something that has been clearly defined and everybody kind of having similar measurable outcomes rather than different one's would definitely help improving the current state and we like to ask Dr. Mandeep would like to add on. Sure, Dr.

Mandeep or Shawn would you guys like to chime in on that. Standardization of data is very critical component of population health management. I would like to introduce our final panelist for today's discussion. And, then we will follow up with some questions from the audience. Good Afternoon, Shawn and I will pass the floor over to you. Thank you Greg! Thank you everyone for coming today my colleague's hit very broad topics and so decided to focus on what we are doing here in Iowa.

We have a very I think a unique situation here in Iowa we have 101 Public Health Departments and we have 99 counties but we have 1 district and local city based Public Health Department that we have 99 county Public Health Departments. About 70 percent of our county public health departments are treating the growing aging population I am not sure if everyone is aware but Iowa is ranked number 4 per capita in the number individuals over the age of 65 and number 1 over the age of 80 and so we are focused on addressing those top 5 percent health issues of those who are most costly often coming with the increasing aging population. One of the things we tried to focus on here is getting the Community Health Needs Assessment cycles together between the non-profit hospitals which are now every three years and the public health departments which are in Iowa are required every five years. Data collection should be ongoing. And, the Community Health Needs Assessment is a reflection of that ongoing data collection. There are many many sources and in Iowa there are some tough one's that people use and our state public health department at the state level had a public tracking portal. We also utilize the County Health Ranking and Road Maps assistance and support quite frequently because you can take a lot of the data sources that are already calibrated although there is a data lag.

But you can use that or at least those sources in your ongoing quality improvement efforts. When you do that there are many many programs evidence-based programs that can address whatever you top 3 health issues that you determine in your assessment that you want to focus on for your population. The biggest issue however is collaboration, who should have a seat at the table. And, more collaboration is needed. Leslie talked about the business impact with productivity losses and so on.. And collaboration with business.

And, I completely agree that more collaboration is needed with business. Unfortunately, Population Health Management now goes into the area of sales. And, making the case to your business partners in your community those stakeholders or the impact on their business the positive impact by assisting public health and the local hospital systems in managing that help their employees.

And then of course, collaborating with social service non-profits there used to doing more with less because that is what they do. Most like Public Health quite frankly. And so if the hospital systems are partnering with business public health is partnering with business and the hospital systems. You should be able to overcome some of the cost issues and improve the public health then producing more economic productive. And, you know it’s a domino effect in an ideal world if everyone were talking. Often the problem is that we are all focused on our own measures so our profits margins and so on.. And, at least from a hospital level and so that is why I think it is hard to collaborate and increase the opportunities for those who should have a seat at the table.

So on that note, I would like to go ahead and ask a poll question. Of those on the call. Does your healthcare organization or Public Health Department work with the Local Public Health Department or if you work in Public Health do you would with you Public Health Department in your area? Wait just a couple more seconds.

I think we have about 20 people 16 people who have not voted. But the majority of you look like you are working with your local public health department to some extent. Which is good. Which is good. Now, the next evolution of that questions is great working with local public now how many of you are collaborating with social service non-profit, and churches, and businesses and other organizations in the community to implement your health improve plans. I want to reference at a practical level a recent article on " Healthcare Informatics" from July 2015 so this month it was released about two weeks ago. Its referencing a Pioneer ACO in Webster county, Iowa with Unity Point Health and Webster County Public Health. They actually their Pioneer ACO covers 8 counties and so with there is collaboration among those 8 counties public health departments as well.

And some of the unique features of their tri-navigation that addresses care coordination and increases connectivity between their providers particularly primary care, mental health, public health. The key feature of their tri-navigation approach is constant communication between the three groups. They use electronic health records through EPIC that is integrated and they are continue to work on this they have some issues at the public health with some of the public health departments getting an interface and they are actually working on that so that they know exactly what the issue is. In the meantime, they have work arounds to increase the discharge planning and care coordination from paper copies of prescriptions and discharge orders, follow up visits, and so on.. With the patients that the patients can carry to their next provider. There also doing a lot of phone calling.

They use care navigators and health coaches. There next step is to continue to build on this by utilizing the data produced from the inter connectivity of these three components primary care, mental health and public health to address their 5 percent with the data analytics. And, of course like I said utilizing the County Health Rankings and Road Maps to integrate with the data they find at their local level compared to the national level and look at programs they can use.

Terry Prescott is the Public Health Administrator in Wester County and she does a great job interfacing with Unity Point COO over their Pioneer ACO. I put on this side you can see here that we talked about care coordination at an application level here in Iowa and what a nice ideal world is that if you have all that information you reduce medication errors, reduce unneeded visits and you increase quality of care by having all of the providers talking. Your are also addressing other components of a person’s health by addressing the mental health and the public health component not just their primary care needs. So one model the Mandeep referred to is Boost in particular because it helps address a lot of the readmission issues for the aging population. And, here in Iowa of course like I referenced that is very important. AHRQ's big three are discharge planning, medication reconciliation and care coordination. And, Boost goes a step further by incorporating patient and family education information through the teaching doc methods. This ideal program if it works and all of the components are running the way they should they you start moment the person is admitted with their discharge planning.

And, a component of that is care coordination. The medication reconciliation are based on communication at all levels with the patient, the family understanding what is expected of them but also their admitting physician their public health department because in Iowa you may be admitted for congestive heart failure say or a cabbage and you have been at the local hospital or the large hospital system and then you go home three or four counties away to your tiny little county population you know 6,000 and your local public health department is the one preventing you from bouncing back their caring for your wound management their coming in doing medication reconciliation their providing public health nursing the home community base services and the skilled nursing services their checking you meds, their managing your diabetes whatever your core morbidity are and so they are an integral part in reducing the cost of readmission and chronic care management. So, those care navigators that they are using in Webster County and those 8 counties covered by the Pioneer ACO they are doing those 24 and 72 hour follow up calls.

In Dallas County Iowa which one of those counties neighboring Polk Counties Des Moines which is one of our largest metropolitan areas our capital of our state. So a patient may be admitted to the large hospital their Mercy or other and they go home to Dallas County we Dallas County Health Public Health has a grant that they are using to help patients fill their medications. Their public health director Shelly Horack was smart, she made sure she wrote that grant so that they would pick their meds up at the local HIVI pharmacy which is our grocery store or the Wal-Mart pharmacy that has a grocery store and so if they have funding to transport these patients there that receive their medications then their also able to make sure they have groceries because that is one of those social determinants of health access to food healthy foods even that goes a step beyond just making sure that there medications are being filled and their prescriptions rather. That is the reason why I am such a big fan of BOOST and a lot of the public health innovation public health is forced to think outside of the box and do more with less and so partnering with them if you’re a healthcare system is smart financial move.

So, how does your organization use advanced analytics to drive population health management initiatives? How do you identify your 5 percent the 5 percent of the population that accounts for 50 percent of the healthcare costs? So, data analytics can support your care teams, your health coaches, your care navigators, so that your primary care physicians can spend more time treating the patient and less time entering all this data. This should be running in the background. This should be something that your care team looks at an on-going basis and not just once every 3 or five years depending what the requirement is. Okay I was able to take away some good information that you shared with us Shawn so thanks for sharing. I going to ask a couple quick questions before we open up the floor to audience for questions.

The first questions is when we examine the 9 areas of quality for example population centered, equitable, proactive, health promoting, risk reducing, vigilant, transparent and effective and efficient do you think it is possible to reach all of these aims. Well I would rather focus on the possibility of trying to reach all of the aims. And, like I said this is through collaboration between these stakeholders in the community. When they both are assessing the health issues and developing the plan to address the issue. Once they have completed that step the process is on-going in their assessment and implementation and evaluation. And so, I sure in an ideal world you would think it is possible, but there are so many unknowns. Every community is different we have a thing we say in Iowa, " If you been in one public health department, you have been in one public health department", and that is why each county does a Community Health Needs Assessment because based on the industry the agriculture others influences in the area, those social determinants of health influence each community differently. Those variables you cannot control for so it is what you control for so it is what you can control for is your process so being proactive, partnering with business, selling the benefits of having people reduce the number of lost days at works and improving their health, reducing their healthcare cost particularly if there self-insured employer.

All those things are on-going and all contribute to ultimately little by little to the improvement in the population's health. Thank you Shawn! I think it is essential strategically examine all of the nine areas and find out what you know where you can use some enhancements and start to create a plan to move away from the norm. One question befor

Population Health Management: Building A Culture Of Wellness And Prevention

Good Afternoon everyone and welcome to The Healthcare Executive webinar series, "Population Health Management: Building a Culture of Wellness and Prevention". My name is Greg Wahlstrom…

By: The Healthcare Executive
Population Health Management: Building A Culture Of Wellness And Prevention

Good Afternoon everyone and welcome to The Healthcare Executive webinar series, "Population Health Management: Building a Culture of Wellness and Prevention". My name is Greg Wahlstrom…

By: Greg Wahlstrom