This document discusses the need to shift from a healthcare system focused on treatment of illness to a population health system focused on preventative care. It notes rising healthcare costs in the US and projections that Medicare and Medicaid will consume all tax revenue by 2050 without reforms. The document outlines Trinity Health's vision of building a "people-centered health system" through initiatives in population health management, care management, and addressing social determinants of health. It provides examples of Trinity Health's work in accountable care organizations, bundled payments, and community engagement initiatives.

1. The Paradigm Shift from
Healthcare to Population Health
Bechara Choucair, M.D.
SVP, Safety Net and Community Health
@choucair
#PPBmeeting
May 23, 2016
The Practical Playbook National Meeting

2. 2©2016 Trinity Health - Livonia, Mich.
Healthcare trends that affect us all:
An urgent need for a paradigm shift

3. 3©2015 Trinity Health - Livonia, MI
U.S. – Spending More for a Shorter Life
The Cost of a Long Life
PerCapitaSpending
AverageLifeExpectancy
United
States
Life Expectancy Per Capita Spending
(International Dollars)

4. 1965: $42B
1975: $134B
1985: $445B
1995: $1T
2005: $2T
2015: $3T
2020: $4.3T
2023: $5.2T
1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023
Historical Total Expenditures
Projected Total Expenditures
4©2015 Trinity Health - Livonia, MI
CMS Projects Health Expenditures to Grow at an Average
Rate of 5.7%,1.1% Points Faster than GDP Growth
To put this into context, if the 2013 US health care
spend of $2.793T was its own country it would be
the 6th largest country in the world
by GDP, larger than the United Kingdom,
Russia, India or Canada
The health spend as a percent
of GDP is expected to rise to
19.3%
up from 17.2% in 2012
by 2023

5. 5©2015 Trinity Health - Livonia, MI
Perspectives
If health care costs in Medicare and Medicaid grow over the next
40 years as rapidly as they did over the previous 40 years, those
two programs will grow from under 5% of the economy today to
20% of the economy by 2050. That is the entire size of the
federal government today and is significantly larger than anything
else affecting the federal budget. It is the fundamental
long-term fiscal challenge facing this country.
“
”— Peter Orszag, former Director of the
Congressional Budget Office (CBO).
"Medicare and Medicaid
are the single biggest
drivers of the federal
deficit and the federal
debt by a huge margin."
— President Barack Obama
“Medicare and Medicaid will cost taxpayers
roughly $1 trillion this year alone. Unless
reforms are enacted, entitlements are on track
to consume all tax revenues before today‘s
25 year-olds are eligible for Medicare.
The status quo is empirically unsustainable.”
— Congressional Budget Office

6. There are 76.4 million Baby Boomers
according to the U.S. Census Bureau
For each of the next 20 years, 3 million
Baby Boomers will reach retirement age
6©2015 Trinity Health - Livonia, MI
The Upside of the Iceberg is Provider’s
Opportunity
By 2030, one in five Americans will be a
senior citizen and require significant health
care services.

7. 7©2015 Trinity Health - Livonia, MI
Costs and Diagnosis of many Chronic Diseases are Expected to
Rise Driven in Part by the Baby Boomers Becoming Seniors
Between 2011 and 2029.
Hospitals performed twice
as many knee replacements
surgeries as they did two decades
ago with replacement projected to
reach 3.5M per year by 2030
according to a 2012 JAMA study.
By 2029, when the last round of boomers
reaches retirement age, the number of
Americans 65 or older will climb to more
71 millionup from about 41 million in 2011
according to Census Bureau estimates.
73%
increase
The number of new cancer cases could
increase 45% by 2030 according to a
2014 ASC Oncology study.
The cost of heart disease
in the U.S. will triple
by 2030 according to a 2011
study commissioned by the
American Heart Association.
More than 50% of
Americans could have
diabetes or prediabetes
by 2020 according to a 2010
UnitedHealth Group study.

8. 8©2016 Trinity Health - Livonia, Mich.
A pivotal transformative moment:
The shift to population health is an
opportunity we cannot afford to miss

9. 9©2015 Trinity Health - Livonia, MI
The Marketplace Demands Fundamental Change
in How We Operate and What We Produce
Producer-
Centered
People-
Centered
Drivers Retail Health Market
Value Networks
Transparency
Financial Incentives
Population
Value
Service
Volume
TOMORROWTODAY

10. 10©2015 Trinity Health - Livonia, MI
Our People-Centered Vision Will Produce the
Population Health Dividend – Real Savings from the
Triple Aim
People-Centered Care
Time
HealthCareSpending
DIVIDEND
Note: Dividend similar to model cited in “Eliminating Waste in US Health Care.”
Berwick, Donald M., Andrew D. Hackbarth, "Eliminating Waste in US Health Care," JAMA 307, no. 14 (April 11, 2012): 1513-6.

11. 11©2016 Trinity Health - Livonia, Mich.
Trinity Health:
We are transitioning to a
People-Centered System

12. 30 million people
We serve diverse populations, with over
in our communities
As a mission-driven innovative health organization,
we will become the national leader in improving the
health of our communities and each person we serve.
We will be the most trusted health partner for life.
12©2015 Trinity Health - Livonia, MI
Our Vision: What We Aspire to Be …
and What We Are Becoming …

13. Our Mission Drives Our Vision and Strategy
We, Trinity Health,
serve together in the spirit of the
Gospel as a compassionate and
transforming healing presence
within our communities.
Our Core Values
Reverence
Commitment
to those who
are poor
Justice Stewardship Integrity
©2015 Trinity Health - Livonia, MI 13

14. Building a “People-Centered Health System”
together
Better Health • Better Care • Lower Costs
Efficient & effective care
management initiatives
Efficient & effective
episode delivery
initiatives
Serving those who are
poor, other populations,
and impacting the social
determinants of health
People-Centered Health System
Community Health
& Well-being
Population Health
Management
Episodic Health Care
Management for
Individuals
14©2016 Trinity Health - Livonia, Mich.

15. 15©2015 Trinity Health - Livonia, MI
Building a “People-Centered Health System”
Together
Better Health • Better Care • Lower Costs
Efficient & effective care
management initiatives
Efficient & effective
episode delivery
initiatives
Serving those who are poor,
other populations, and
impacting the social
determinants of health
People-Centered Health System
Community Health
& Well-being
Population Health
Management
Episodic Health Care
Management for
Individuals

16. *Owned, managed or in JOAs or JVs.
**Operations are organized into Regional Health Ministries ("RHMs"), each an operating division which maintains a governing body with managerial oversight subject to authorities.
Our 21-State
Diversified Network
Home Care & Hospice
Locations Serving 116 Counties47
Continuing Care
Facilities59
PACE Center
Locations14
Hospitals* in 20 Regional
Health Ministries**92
Employed
Physicians3.9K
Affiliated
Physicians23.9K
16©2016 Trinity Health - Livonia, Mich.

17. 17©2016 Trinity Health - Livonia, Mich.
We operate one of the largest clinical episode
payment programs in the nation
• 43 Model 2 Bundled Payment for Care Improvement (BPCI) hospitals
• 13 Model 3 Skilled Nursing Facilities (SNF)
• 2 Comprehensive Joint Replacement (CJR) sites
• 22,400 total annual episodes for all three programs
BPCI
SNF
CJR

18. 18©2016 Trinity Health - Livonia, Mich.
We are working to improve care across clinical
conditions with 43 of 48 possible bundles
(in millions)
Total Program Size: $550m

19. 19©2015 Trinity Health - Livonia, MI
Building a “People-Centered Health System”
Together
Better Health • Better Care • Lower Costs
Efficient & effective care
management initiatives
Efficient & effective
episode delivery
initiatives
Serving those who are poor,
other populations, and
impacting the social
determinants of health
People-Centered Health System
Community Health
& Well-being
Population Health
Management
Episodic Health Care
Management for
Individuals

20. We continue to invest in increasing attributed lives
and building capabilities
FY14 FY15 FY16
Total Number of ACOs, Attributed Lives
and Annual Investment
Attributed LivesACOs Annual Investment
Since FY14, Trinity Health
has invested over $90M
in support of population
health management efforts
Investments have
promoted continual
growth in both MSSP
and commercial ACOs
$16.5M
$25.0M
$48.9M
34 ACOs
30 ACOs
11 ACOs
1,245,750
1,121,000
640,000
20©2016 Trinity Health - Livonia, Mich.

21. 21©2016 Trinity Health - Livonia, Mich.
Expanding ACO programs are the primary driver
of APM growth
• 14 Medicare Shared Savings Program ACOs
• 5 markets partnering as a Next Generation ACO
• Participating in 98 non-CMS APM contracts
• 13.8K physicians participating in our Clinically Integrated Networks
accountable for 1.2 million lives
Medicare Shared SavingsNext Gen ACO

22. Trinity Health made an
initial investment in ACOs
of $16.5M in FY14
Of the total $44.2M
generated, $16.9M
of the savings was shared
with Trinity Health ACOs
Our initial ACO investments have yielded positive
shared savings
Investment
in ACOs
Total Savings
Generated
$16.5M
$27.3M
Payer Share
$16.9M
ACO Share
$44.2M
22©2016 Trinity Health - Livonia, Mich.

23. IT infrastructure
and data-driven
claims analysis
Combining internal
claims data platform and
analytic resources with
industry-recognized
tools to report provider
performance across the
enterprise to provider
levels
Standardized care
management
process across the
continuum
Maximize
efficiency in post-
acute and SNF care
Reduce unnecessary
or avoidable
hospitalizations
New operating capabilities improve care and lower
cost for patients in ACOs
Targeting high risk
patients through
predictive modeling and
coordinating patient
care through
multidisciplinary teams
at the site of care
Identifying clinicians to
focus on SNF population
and collaboratively
manage transitions
alongside BPCI teams,
utilizing home care
partnerships
Improving access to
primary and specialty
care providers, engaging
hospitalists in adhering
to transitions of care
processes
23©2016 Trinity Health - Livonia, Mich.

24. 24©2015 Trinity Health - Livonia, MI
Building a “People-Centered Health System”
Together
Better Health • Better Care • Lower Costs
Efficient & effective care
management initiatives
Efficient & effective
episode delivery
initiatives
Serving those who are poor,
other populations, and
impacting the social
determinants of health
People-Centered Health System
Community Health
& Well-being
Population Health
Management
Episodic Health Care
Management for
Individuals

25. Community
Engagement:
Clinical Services:
Community Health & Well-being
Efficient & Effective Care
Delivery through Trinity’s
Safety Net System
Triple Aim
Better health Better care Lower costs
Efficient & Effective Wrap Around
Services Focusing on the Vulnerable & the
Poor
Community
Transformation:
Community Building Focusing on
Built-Environment Economic
Revitalization, Housing, & other
Social Determinants of Health
Innovation in Care Delivery
Innovation in Technology
Innovation in Financing
Transforming, Healing Presence in the Communities We Serve
©2015 Trinity Health - Livonia, MI 25

26. Community
Engagement:
Clinical Services:
Community Health & Well-being
Efficient & Effective Care
Delivery through Trinity’s
Safety Net System
Triple Aim
Better health Better care Lower costs
Efficient & Effective Wrap Around
Services Focusing on the Vulnerable & the
Poor
Community
Transformation:
Community Building Focusing on
Built-Environment Economic
Revitalization, Housing, & other
Social Determinants of Health
Innovation in Care Delivery
Innovation in Technology
Innovation in Financing
Transforming, Healing Presence in the Communities We Serve
©2015 Trinity Health - Livonia, MI 26

27. Dual eligible beneficiaries are among the poorest and
sickest beneficiaries covered by either program.
Most have multiple chronic conditions.
Nearly half have significant mental illnesses.
In 2013, over 10.7 million individuals
were dually eligible for Medicare
and Medicaid benefits.
Transforming Safety Net Care with a Focus on the Duals
©2015 Trinity Health - Livonia, MI 27

28. ©2014 Trinity Health. All Rights Reserved. 28Innovation Council - Internal ©2015 Trinity Health - Livonia, MI
Nationally, Duals accounted
for a total of $284.5B in
spending in FY ’10. Today,
spending is estimated to
exceed $300B.
Spending on the “Duals”
accounts for approximately
2% of GDP.
Trinity Health provides care to
more than 207k Dual-eligible
patients, representing $1.5
Billion in acute care revenue,
annually.
©2015 Trinity Health - Livonia, MI 28
Spending on Dual-eligible Patients is High
Innovation Program – Internal @2016 Trinity Health – Livonia, MI 28

29. 29©2015 Trinity Health - Livonia, Mich.
http://trinityhealthchallenges.org

30. May 2, 2016 Challenge launch
June 10, 2016 Letter of Inquiry (LOI) deadline
July 15, 2016 Notify if invited to complete an application
August 19, 2016 Application deadline
September 26, 2016 Innovation Council meeting/ virtual showcase
October 15, 2016 Announce awards!
3030
Challenge Timeline
©2016 Trinity Health - Livonia, Mich.

31. Community
Engagement:
Clinical Services:
Community Health & Well-being
Efficient & Effective Care
Delivery through Trinity’s
Safety Net System
Triple Aim
Better health Better care Lower costs
Efficient & Effective Wrap Around
Services Focusing on the Vulnerable & the
Poor
Community
Transformation:
Community Building Focusing on
Built-Environment Economic
Revitalization, Housing, & other
Social Determinants of Health
Innovation in Care Delivery
Innovation in Technology
Innovation in Financing
Transforming, Healing Presence in the Communities We Serve
©2015 Trinity Health - Livonia, MI 31

32. 32©2015 Trinity Health - Livonia, MI
What Drives Good Health Outcomes?
Access and Quality of Care ≈ 20%

33. Self-Referral
or by Family
or Friend
Homeless
Shelter
Community
Transport
Services
Independent
Physicians
Our Desired Future:
Better Health, Better Care, Lower Cost
33
Inpatient
Acute Care
Continuing
Care
ED
Employed &
Independent
Physicians
HUB
CHWs &
Data
Medication
Assistance
Insurance
Enrollment
Pregnancy
Assistance
Social
Services
Care Management
Programs
(e.g., Faith Nursing;
Complex Care)
Integrated Delivery
Network
NOTE: Examples of
HUB services. Many
others are sponsored by
the community/RHM.
Nature of our Ministry:
Community at Large (501r)
Behavioral
Health
Social Determinants
(e.g., Race/Ethnicity,
Gender, Income Level,
Language, Literacy, Living
Location)
Data Data
ACO
Sample
Referral
Sources
©2015 Trinity Health - Livonia, MI 33

34. 34©2015 Trinity Health - Livonia, MI
We Can Make a Real Difference in Patients’ Lives
Muskegon Health Project
Pathways to a Healthy Pregnancy
Muskegon, MI
Katrena H.
Patient
Ka’Ziya H.
Baby&
Pre-Community
Health Worker
Involvement
• Homeless
• High-risk
pregnancy
• Needing
prenatal care
Post-Community
Health Worker
Involvement
• Has housing and
resources for new home
• Received prenatal care
• Delivered a healthy baby
Before we met you, we were
homeless and we were going
from place to place.
- Katrena H.

35. Deployment of 50 Community Health Coordinators
Part of a 2015
AmeriCorps
Partnership
Challenge Grant
Community
Health
Workers
Up to 10
CHWs
deployed in
each targeted
MSSP and
BPCI program
Focus on
the Duals
Advanced
analytics to
identify
highest-risk
patients
Deploy CHWs &
HUB / Pathways
Model to address
social needs
Community Engagement
©2015 Trinity Health - Livonia, MI 35

36. Measuring Impact
Existing MSSP ACO metrics / dashboards
will be used to evaluate the impact of
deploying up to 10 CHW at each of the 6
targeted ACOs.
©2015 Trinity Health - Livonia, MI 36

37. Community
Engagement:
Clinical Services:
Community Health & Well-being
Efficient & Effective Care
Delivery through Trinity’s
Safety Net System
Triple Aim
Better health Better care Lower costs
Efficient & Effective Wrap Around
Services Focusing on the Vulnerable & the
Poor
Community
Transformation:
Community Building Focusing on
Built-Environment Economic
Revitalization, Housing, & other
Social Determinants of Health
Innovation in Care Delivery
Innovation in Technology
Innovation in Financing
Transforming, Healing Presence in the Communities We Serve
©2015 Trinity Health - Livonia, MI 37

38. Health Does Not Begin In A Doctors Office…
Access to healthy
and affordable
food
Built-environment
Race / Ethnicity
Economic
opportunity
Educational
opportunity
Root Causes of
Good vs. Poor Health
Safe places for kids
to learn and play
Food and beverage
environment in
schools
Socioeconomic
status / Income
Other social
determinants of
health
Clinical care
(just the tip of the iceberg)
©2015 Trinity Health - Livonia, MI 38

39. 39©2015 Trinity Health - Livonia, MI
Anticipated investment of
$80 million over 5 years in
community health interventions.
Funding local partners with
Several national partners at the
table.
Applications are led by
Community Coalitions, Local
public health agencies & Trinity
Health Ministries
$17.5 M
Transforming Communities Funding Opportunity
Launched in Nov 2015

40. • Boise, ID (Promise Partnership)
• Maywood, IL (Proviso Partners for Health)
• Silver Spring, MD (Healthy Montgomery)
• Springfield, MA (Live Well Springfield TCI Partnership)
• Syracuse, NY (Syracuse Health Coalition)
• Trenton, NJ (Trenton Health Team)
40©2015 Trinity Health - Livonia, Mich.
Six Communities Selected to Be Funded:

41. • Implementation of Tobacco 21 policy
• Development/ implementation of Complete Streets Policies
• Implementation of Nutrition Standards in Head-start & Daycare
• Enhancement of Breastfeeding Policies
• Expanding Physical Activity School Board Policies
• Implementing Food and Beverage Standards/Policies in Schools
41©2015 Trinity Health - Livonia, Mich.
Select Strategies to be Implemented Across all
Six Communities

42. 42©2015 Trinity Health - Livonia, Mich.
Tobacco policy work is integral to our Community
Health and Well-Being strategy.
The longevity gaps in America are growing, not
shrinking.
CDC researchers have concluded disparities in tobacco
use account for 20% to one-third of growing life
expectancy gaps.
Living in locations that have not adopted strong tobacco
control measures is directly correlated with growing
health disparities and longevity gaps.
Our commitment to vulnerable populations, especially
people who are poor, demands action.

43. 43©2015 Trinity Health - Livonia, MI
Our Tobacco Policy Focus
• Pass and/or Strengthen Clean
Indoor Air Laws
• Tobacco Free Campus Policies
• Tobacco 21: Raising the Legal
Purchase Age to 21
Community Transformation

44. ©2016 Trinity Health - Livonia, MI
of Americans live in states with strong
state-level protections. Everyone else relies
on local governments to close the gap, or
must advocate for state-level changes.
53%
Source: Americans for Non-Smokers Rights.
6 States In Our
Network Diversified
Network
Loopholes for many
workplaces and bars
Loopholes for bars
Loopholes for bars
and restaurants
No state law!
states within our footprint have
weak clean indoor air laws for
combustible cigarettes6
Strong state law
A Patch-Work Quilt of SmokeFree Laws Leave Many Behind

45. Institute of Medicine
Tobacco 21 Will Reduce
Smoking and Save Lives

46. ©2015 Trinity Health - Livonia, MI
46
decline in smoking
initiation by 15-17
year olds
25% overall drop
in smoking
prevalence
12% reduction of
smoking related
deaths
10%
For kids alive today, 4.2 million years of life would be
saved by virtue of this logical, simple policy change.
Other Important Impacts…
Decline in
premature births12%
Drop in
SIDS cases16%
©2015 Trinity Health - Livonia, MI
Tobacco 21: Over time…

47. 47©2015 Trinity Health - Livonia, Mich.
In 2016, alone, we’ve experienced big wins in many
of the communities we serve.
• January 11: New Jersey passed Tobacco 21 law (pocket veto)
• March 16: Chicago passes Tobacco 21 and other historic measures
• March 29: South Bend passes state’s strongest smoking ban
• April 12: Washington, D.C. Congressional briefing likely to result in
several additional co-sponsors on Federal legislation
• April 26: Albany County passed Tobacco 21 (bill not yet signed)
• May 10: California Tobacco 21 and other historic bills signed into law
• May 18: Illinois Tobacco 21 passed out of the Senate

48. Building a “People-Centered Health System” together
Better Health • Better Care • Lower Costs
Efficient & effective care
management initiatives
Efficient & effective
episode delivery
initiatives
Serving those who are
poor, other populations,
and impacting the social
determinants of health
People-Centered Health System
Community Health
& Well-being
Population Health
Management
Episodic Health Care
Management for
Individuals
48©2016 Trinity Health - Livonia, Mich.

49. Discussion…
@choucair
#PPBmeeting