Preparing for Health Care Reform: An Opportunity for CP Rehab Professionals

1. Preparing for Health Care Reform: An Opportunity for CP Rehab Professionals Zack Klint, MS, CES Coordinator, Cardiopulmonary Rehabilitation Vanderbilt University Medical Center

2. Disclosure Information I have no conflict of interest. Acknowledgements Jay Groves, EdD, MMHC EB Jackson, MBA Allison Jagoda, MS, CES

3. The US Health Care Spend

4. Per Capita Health Care Spend

7. Care Quality; How do we Compare?

8. Health Spending and Longevity

9. “The cost of sickness in America is a threat to the country’s economic security” D.W. Edington, PhD University of Michigan, HMRC

10. HC Reform and Family income

11. “The Health Care Reform Crossroads”

12. Health Care Reform; It is all About the Change “Ultimately, all change efforts boil down to the same mission; Can you get people to start behaving in a new way?” Chip Heath, Dan Heath, “Switch: How to Change Things When Change is Hard” 2010.

13. The “New Way” of Health Care For Health Care reform, the “New Way” must include changes from: • Government • Payers • Providers • Employers • Individuals

14. The Business of Health “We are in the sickness business. We need to get into the health business”. Dr. Delos Cosgrove, Chief Executive Officer Cleveland Clinic, Time Magazine, June, 2009

15. Managing Health Health Care Shift Passive Participant Informed Decision Maker Health Care Cost Health Care Investment Treating Disease Cost-Shifting Realigning Cost-Share Fragmented Integrated / Connected

17. Core Elements of Health Care Reform • Accountable Care Organizations • Bundled Payments

18. A Model for ACO’s

19. Proposed Benefits of ACO’s

20. Potential Impact of ACO’s on the Delivery of CP Rehabilitation Services • Premium on care coordination. • Expanded and new care coordination teams. • Consistent outcome measures across the continuum of care. • Must expand your reach and impact. • “The right care, for the right patient, at the right time”. • Outcomes! Outcomes! Outcomes!

21. Bundled Payments for Care

22. Bundled vs Fee-for-Service Payments

23. What is Included in the Bundle? • In-patient costs • Out-patient costs (0-180 days) • Diagnostics • Prescriptions • Bonus payments for achieving cost and quality standards

24. Value-based Metrics

25. The Importance of Wellness in Health Care Reform

26. The Causes and Costs of Avoidable Chronic Illnesses • The combined cost of the top 7 modifiable chronic diseases (cancer, diabetes, hypertension, stroke, heart disease, pulmonary conditions and mental disorders) exceeds $270B annually in direct costs and reaches over $1T annually with lost productivity. • It is estimated that 70% of avoidable health care costs could be mitigated by behavior changes that involve healthy lifestyle development, wellness enhancement and early detection for the conditions listed above. (Source: “A Wellness Initiative for the Nation”, February 6th, 2009, The Samueli Institute)

27. The Causes and Costs cont…. Five behavioral risk factors have been shown to contribute the most to mitigating these costs; 1) Reducing toxic substance exposure- smoking, alcohol, drugs and pollution 2) Sufficient exercise and physical activity 3) Healthy diet 4) Psychosocial integration and stress management 5) Early detection and intervention It is estimated that even modest gains in smoking and obesity control would reduce illness in the top seven modifiable chronic health conditions by 24-30 million, save up to $100B in treatment costs.

28. Potential Impact of Bundled Payments on the Delivery of CP Rehab Services • A chance to “re-invent the wheel”. • Must contribute to the “value proposition”. • Renewed emphasis on sustainable, behavior change (patient engagement). • Must have “real time” data to drive care decisions. • May need a different skill set. • May need to do more with less.

29. Opportunity is here • How do we give patients “everything they need and nothing they don’t?” • Standardize care according to evidence-based care pathways • Improve the “tools” our teams rely on to deliver the best care for every patient, every time • Facilitate personalized medicine by building in appropriate flexibility and customization based on clinical presentation, patient history • (BETTER) QUALITY • Safe, Evidence-Based Best Practices • Coordinate Care Across Continuum • Patient Service Experience Value • (LOWER) COST • Eliminate Unneeded Care • Efficient Workflows • Practice at Top of License

31. ACS Bundle ACS Continuum (6 mos)

32. Acute Coronary Syndrome Bundle: Project Goals Institutional Goals • Explore capabilities needed to deliver coordinated care and manage clinical and financial risk under a bundled reimbursement model Outcomes Goal • Reduce rate of non-value-added downstream encounters and downstream ischemic events following an initial episode of Acute Coronary Syndrome • Lower score for “9 Modifiable Cardiac Risk Factors” over the defined episode Financial Goals • Create clinical capacity (inpatient, Dx and therapeutic) • Limit healthcare spend over time for ACS patients, demonstrating value to payers & employers • Reduce avoidable related readmissions • Minimize repeat Dx tests, re-caths & downstream interventions • Minimize avoidable complications

33. ACS Demonstration Pilot Progress Up Next! CritPathwCardiol. 2011 Mar; 10(1):1-8

34. Clinical Success:Modifiable Cardiac Risk Factors Circulation, 2007

35. ACS Cardiac Rehab Pilot 26 Week Comprehensive Risk Reduction Program

36. Cardiac Rehab – Fee For Service • Where does it fall short? • Missing eligible patients • Limited access due to finances • No reimbursement for medical management • Financial mechanism doesn’t incentivize value • Quality – no premium on outcomes • VISITS = REVENUE

37. Cardiac Rehab – Bundled Payment • GLOVES ARE OFF • Improves flexibility for supervised exercise • Visits ≠ Revenue • Risk Stratification • Payment for LIFESTYLE MEDICINE • Supporting Change • Opportunities to tap other disciplines expertise when appropriate • Health Coaching, Health Psychology, RD, etc • “Everything they need, nothing they don’t”

38. Major Lifestyle DomainsWhat do we want to change? Nutrition Medication Adherence Tobacco Cessation CR Pilot Exercise & Physical Activity Psycho Emotional Health

39. Tools to address behavior by domain

40. Key Components ACS Cardiac Rehab

41. ACS Cardiac Rehab Algorithm

42. Health Coaching – CR staff • WellCoaches®Certification • Strategic initiative at Vanderbilt Dayani Center andVanderbilt Center for Integrative Health • CR staff trained as Health Coaches • Outpatient - 3 of 4 staff certified (4 of 4 soon) • Inpatient - 1 of 3 staff certified

43. Clinical Success: Circulation, 2007

44. Iterative Small Tests of Change

45. ACS 10 patient pilot • Organization -Test the ACS pathway (inpatient through 3 months + post-discharge) • Manually move 10 patients from admission to 7 day visit and into outpatient management • Opportunity for CR • Pilot the Health Coaching model in outpatient cardiac rehab

46. ACS 10 patient pilot • Fee for service CR + 6 health coach sessions • 1 (60min) and 5 (30 min) • Goals • Testing – Too many cooks in the kitchen? • Test phone call model • Any influence on outcomes

47. Modifiable risk factor outcomes

48. Improved Capture Rate?

49. Improved Adherence?

50. My Conclusions • CPR programs/professionals are well positioned to play essential roles as behavior change specialists in an era of health care reform • Health Coach • Health Navigator • Patient Engagement • Outcomes