A session by Amish Purohit, CEO and CMO, US Health Systems on the topic of 'Population Health Management & Volume To Value Based Care' at IFAH USA 2019 held at Caesars Palace, 18-20 June, 2019.

1. Population Health
Management and Volume To
Value Based Care
Amish Purohit, MD, MHA , CPE, FAAFP, FACHE
Chief Executive Officer and Chief Medical Officer
US Health Systems

3. Access to Health Care

8. 8
Medicine: Key Points
• Health care in the U.S. today is more expensive, and this is primarily because of
premium medicine.
• U.S. health care today utilizes more physical capital and human capital than
before or elsewhere.
• Premium medicine reflects cultural expectations of a high level of effort to
diagnose correctly and treat effectively.
• Evidence is mixed about whether it has increased the benefits of health care.
• We have conquered many infectious diseases. Now we are tackling degenerative
diseases which cost more for less marginal benefit.
• We’ll spend more and more for less and less improvement.

9. Institute for Healthcare Improvement:
Brief History
• IHI vision began during the 1980’s as
the National Demonstration Project
on Quality Improvement in Health
Care
• Founded in 1991, Dr. Don Berwick-
Harvard Medical School
• 2010 appointed by President Obama
to become the Administrator of CMS

10. Institute for Healthcare Improvement: History
• Focus “Best Practice” changing the way hospitals & healthcare systems provide care
• Innovative solutions to “old problems” resulting in the 100,000 Lives Campaign & 5 Million Lives
Campaign to improve population health
• Created the Triple Aim as a framework for optimizing health system performance

11. Institute for Healthcare Improvement: Journey
• Created awareness, education
and global collaborative efforts
for quality improvement
opportunities

12. Institute for Healthcare Improvement:
Journey-Driving Improvement
• Redesign: “Best Practice” & 1st International Summit on Redesigning the Clinical Office Practice
(1999-2000)
• Cooperation: “Unification” addressing disparities in healthcare (2002 – 2004)
• Full Scale Operations: Deploys the objective of Quality Care globally and the official “Go Live” of
the Triple Aim initiative (2005-2007)
• Global Expansion: Welsh Government launched a campaign to avoid 50,000 “episodes of harm”
in two years (2008)

13. Thou shall not harm me! I don’t bite…I promise!

14. So what’s
TRIPLE AIM?

15. Institute for Healthcare
Improvement:
Triple Aim
• Improve Health of a Population
Population Health Management
• Improve experience of care for
individuals within that population
Improved Patient Experience
• Improve the per capita cost of providing
care
Decrease per capita cost

17. Care for Populations (2010-2014)
• Population Health
Management accelerates
• Triple Aim expands efforts
towards making care better
for patients and reducing
per capita cost

18. TRIPLE AIM to Quadruple AIM
Concept or Concrete
Foundation?
Fee-for-Service
Value-based care
4th Dimension….improving the work life of
those who deliver care

19. Quadruple AIM: The “4th Dimension”
• Triple Aim initiatives have had vital influence in improving
quality healthcare
• HOWEVER… ↑ Provider
Burnout

20. Practice Demands
• EHR Requirements
• Time consuming
documentation
• Addressing alerts/
reminders
• Business operations
• Billing, claims, AR
• Staffing
• Liability concerns

21. • Dissatisfied
providers are 2-3
times more likely to
leave practice
• Spinelli,Wm. The phantom limb of the triple aim. Mayo Clinic 2013:88 (12): 1356-1357.

24. The 4th AIM: Improving the work life of those who
deliver care
• 1. Work effort
• 2. Work efficiency and support
• 3. Flexibility and control at work
• 4. Value and meaning in work
• 5. Management of work-home
interference (overlap)
Five key
drivers
•Friedberg MW, Chen PG, Van Busum KR, et al. Factors affecting physician professional satisfaction and their
implications for patient care, health systems, and health policy. Santa Monica, CA: RAND Corporation; 2
5 key drivers of job
satisfaction

25. Addressing Burnout
• Implement team documentation
(scribes) to assist with order
entry, Rx processing, charge
capture
• Use pre-visit planning and pre-
appointment lab testing to
enhance visit efficiency more
meaningful provider/patient
encounter
• Standing orders and protocols
for education on preventive care
and chronic care health
coaching that can be conducted
by clinical staff

26. TRUE OR FALSE
• The Triple Aim effort has
contributed to an increase in
provider burnout.
TRUE

27. Documentation and
Understanding Medicare Risk
Adjustment

28. The RAF (Risk Adjustment Factor)
• Lower RAF = healthier population
• Higher RAF = sicker population
RAF score identifies
patient health
status
• RAF follows a Medicare beneficiary
wherever they are in the country
Average RAF score
for a Medicare
beneficiary is 1.000

29. Importance of Coding Accurately - Sample
All conditions coded appropriately Some conditions coded – poor specificity No conditions coded
76 y/o female 0.437 76 y/o female 0.437 76 y/o female 0.437
Medicaid eligible 0.151 Medicaid eligible 0.151 Medicaid eligible 0.151
Diabetes with chronic
complications
DM w/ peripheral
circulatory disorders
0.368 Diabetes without
complications
Type II DM
0.118 No diabetes coded
Vascular disease w/
complications
Atherosclerosis of
native artery of
extremity
w/ulceration
0.410 Vascular disease w/o
complications
PVD
0.299 No vascular disease
coded
CHF
Systolic HF
0.368 CHF not coded CHF not coded
Disease Interaction
(DM + CHF)
0.182 No Disease
Interaction
No Disease
Interaction
Total RAF 1.916 Total RAF 1.005 Total RAF 0.588
*Weightings are for demonstration purposes ONLY.

30. Documenting
All
Conditions
Accurate documentation
Substantiated by appropriate
medical evidence, including clinical
judgment
Note supports the diagnosis
New vs. Existing
Diagnoses
Logic statement (New)
Evaluative statement
(Existing)

31. Quality Measures,
STAR Ratings

32. 2019 Medicare Star Measures
DOMAIN 1:
Staying Healthy, Screening,
Tests and Vaccines
DOMAIN 3:
Member Experience with
Health Plan
DOMAIN 2:
Managing Chronic
(Long Term) Conditions
PART D
4 DOMAINS
few measures
DOMAIN 5:
Health Plan
Customer Service
DOMAIN 4:
Member Complaints,
Problems Getting Services
& Improvement in the
Health Plan’s Performance
 Adult BMI Assessment
 Annual Flu Vaccine
 Breast Cancer Screening
 Colorectal Cancer
Screening
 Improving or Maintaining
Mental Health
 Improving or Maintaining
Physical Health
 Monitoring Physical
Activity
 Care of Older Adults: Functional
Status Assessment
 Care of Older Adults:
Medication Review
 Care of Older Adults: Pain
Assessment
 Controlling Blood Pressure
 Diabetes Care: Blood Sugar
Controlled
 Diabetes Care: Eye Exam
 Diabetes Care: Kidney Disease
Monitoring
 Osteoporosis Management in
Women Who Had a Fracture
 Plan All-Cause Readmission
 Rheumatoid Arthritis
Management
 Special Needs Plan (SNP) Care
Management
 Improving Bladder Control
 Medication Reconciliation Post-
discharge
 Care Coordination
 Customer Service
 Getting Appointments
and Care Quickly
 Getting Needed Care
 Rating of Healthcare
Quality
 Rating of Health Plan
 Complaints about the
Health Plan
 Health Plan Quality
Improvement
 Members choosing to
Leave the Plan
 Call Center: Foreign
Language Interpreter &
TTY Availability
 Plan Makes Timely
Decision About Appeals
 Reviewing Appeals
Decisions
 Call Center: Foreign
Language Interpreter & TTY
Availability
 Medication Therapy
Management (MTM)
Program Completion Rate
for Comprehensive
Medication Review (CMR)
 Complaints about the Drug
PlanGetting Needed
Prescription drugs
 Medication Adherence for:
Diabetes, Hypertension (RAS
antagonist,) Cholesterol
 Medication Adherence for
Diabetes
 Statins for Diabetes
 Members choosing to Leave
the Plan
 Rating of Drug Plan

33. CMS Places Greater Importance on Outcomes Measures Compared to
Process Measures in Calculating Overall Scores
Process Measures
Patient Experience and
Access Measures
Intermediate Outcomes
Measures
Outcome Measures
Measure-level star rating multiplies by weight of 1.0
Measure-level star rating multiplies by weight of 1.5
Measure-level star rating multiplied by weight of 3.0
Measure-level star rating multiplied by weight of 3.0
Providers directly influence 80% of the Stars rating

34. MEASURE PART C STAR
WEIGHT
MEASURE PART D STAR
WEIGHT
CO1 BREAST CANCER SCREENING 1 D10 MEDICATION ADHERENCE FOR
DIABETES MEDICATIONS
3
CO2 COLORECTAL CANCER SCREENING 1 D11 MEDICATION ADHERENCE FOR
HYPERTENSION (RAS ANTAGONISTS)
3
C13 DIABETES CARE – EYE EXAM 1 D12 MEDICATION ADHERENCE FOR
CHOLESTEROL (STATINS)
3
C14 DIABETES CARE – KIDNEY DISEASE
MONITORING
1 D14 STATIN USE IN PERSON W/DIABETES 1
C16 CONTROLLING BLOOD PRESSURE 3
C21 PLAN ALL-CAUSE READMISSIONS 3
Focus Measures

35. Triple Weighted Measures
Measure Part C Star
weight
Measure Part D Star
weight
CO4 Improving or maintaining
physical Health
3 D10 Medication Adherence for
Diabetes Medication
3
CO5 Improving or maintaining
Mental Health
3 D11 Medication Adherence for
Hypertension
3
C15 Diabetes Care- Blood sugar
Controlled
3 D12 Medication Adherence for
Cholesterol (statin)
3
C16 Controlling Blood Pressure 3
C21 Plan All- Cause Readmission 3

36. HOS Surveys
Health Outcome Surveys (HOS): Patient reported outcomes that gathers
valid, meaningful health data to improve quality of healthcare.
• HOS Measures are included in the STAR Ratings for MA Quality Bonus
Payments
HOS Questions
Improving or maintaining physical health
Improving or maintaining mental health
Monitoring Physical Activity
Improving Bladder Control
Reducing the Risk of Falling

37. CAHPS Surveys
Consumer Assessment of Healthcare Providers & Systems (CAHPS):
• CMS Surveys patients between March and June about experience with health care providers and
plans, results are publically reported
• Patient’s perception of their healthcare
• CAHPS data are included in the STAR Ratings and used to calculate MA Quality bonus payments
CAHPS Questions
Getting Needed Care
Getting Appointments and Care
Doctors Who Communicate Well
Customer Service
Getting Needed Prescription Drugs
Care Coordination
Annual Flu Vaccine
Pneumonia Vaccine
Rating of Health Plan
Rating of Health Care Quality
Rating of Drug Plan
Category
Doctor-Patient Communication
Overall Ratings- Provider:
Timely Access to Care
Office Staff Courtesy
Overall Office Experience
Continuity and Care of Coordination
UM/Authorization-Specialty Care or
Procedure

39. Volume to Value
• 1965 Medicare enacted
• Since then US Health Care:Volume Based System
• Increased health care expenditures with no improvement in
mortality and morbidity or health outcomes
• Value Based Care
• Driven by payers (Medicare being the largest-Triple AIM)
• Achieved through population health management

40. Population Health
• “Population health management is a clinical discipline that
develops, implements and continually refines operational
that improve the measures of health status for defined
• Resulting in decreased costs
• Improved Health Outcomes

41. Population Health
• Tools
•Risk Stratification
•Notifications and Alerts
•HIE, Experien
•Care Management Platforms
•Care Gap Analytics
•Documentation
•Maximizing RAF

42. Tools
CarePointe predictive analytics – Integrated program utilized for predictive
analytics of patient risk identification and stratification for Care Management
patients across multiple variables and risk factors

43. Population Health
Programs and Strategy
• Transitional Care
• Complex Care Management
• Palliative Care
• Emergency Room Care Coordination
• Post-Acute Network Management
• Comprehensive Health Assessment
• Resources to address Social Determinants
of Health

45. Coolidge, AZ

46. Homer the
snake…
Casa Grande,
AZ

47. Questions?