1. Population Health: Matching Patient Risk with Provider Resources 4th Annual EDM Forum Symposium June 7 th, 2014 Tracy Johnson, PhD, MA; Deborah Rinehart, PhD, MA; Josh Durfee, MSPH; Dan Brewer; Elizabeth Huxster, MS, MBA, Kathy Thompson, MA; Holly Batal, MD, MBA; Josh Blum, MD; Paul Melinkovich, MD; Patricia Gabow, MD.

2. © 2012 Denver Health Denver Health and Hospital Authority 2 Denver Cares Correctional Care Denver Health Medical Center 911911 Family Health Centers Regional Poison Center & Nurseline Denver Health Medical Plan School- based Health Centers Rocky Mtn Center for Medical Response to Terrorism Public Health Rocky Mtn Regional Trauma Ctr

3. © 2012 Denver Health What Is and Why Focus on Population Health? “…the practice of determining the health and health needs of a population by measuring and reporting factors that may influence an individual's health.” (U.S. Department of Veterans Affairs) Includes factors beyond lab results and tests, such as behavior, environment, and environmental conditions Looks for patterns in data to be transformed into useful knowledge to improve health outcomes

4. © 2012 Denver Health Purpose of Risk Stratification Goals – Tiering of patients based on risk stratifications to match resources and case management appropriately – Improve quality of care while lowering costs – Improve financial sustainability Methods – Clinical Risk Groups (CRGs) Dx, pharmacy, actual vs. project utilization – Registry Information – Demographic Characteristics, Health Risk Assessments (future) – Historical Data – Predictive Modeling and Simulations Tier 4 Tier 3 Tier 2 Tier 1

5. © 2012 Denver Health Tiered Service Delivery Model Patient CountsProject Services 79,946 Adult 26%, Peds 74% 43,225 Adult 82%, Peds 18% 3,435 Adult 75%, Peds 25% PN BHC HIT PN, RN, PharmD, BHC, HIT Multidisciplinary High Risk Health Teams Baseline PBPYs $54,384 $27,270 $5,152 $742 Tier 4 Tier 3 Tier 2 Tier 1 HIT 1,283 Adult 62%, Peds 38%

6. © 2012 Denver Health Patient Numbers By Tier Project Services By Tier Tier 1 n = 54,261 Tier 2 n = 38,767 Tier 3 n = 4,658 Tier 4 n = 1,514 Tier 1 Automated services, (HIT) Tier 2 PN, BH, HIT Tier 3 Enhanced PN, BH Pediatric RN, Pharmacy, HIT Tier 4 “High Risk Teams” Tier DH Adult High Risk Clinic MHCD Adult High Risk Clinic CSHCN High Risk Clinic Baseline PBPYs $69,805 $8,798 $4,601 $1,490 LEGEND BH= Behavioral Health Consultant PN= Patient Navigation HIT= Health Information Technology Tier 0 (Not yet Tiered) n = 30,236 PBPY = $1,828 Tiering 1.0 Algorithm

7. © 2012 Denver Health CRGs Provide Financial Stratification with Clinical Meaning CRG* Status2011 ADULT average charges 2012 ADULT average charges 2013 ADULT average charges 1 - Healthy $2,427$2,511$2,879 2 - Acute Only $7,021$8,141$9,407 3 – Single Minor Chronic $5,698$5,691$6,280 4 – Multiple Minor Chronic Disease $6,855$7,840$8,516 5 – Moderate Chronic Disease $7,610$7,684$7,768 6 - Significant Multiple Chronic $20,324$21,147$21,449 7 – Dominant Multiple Chronic $58,631$64,823$69,406 8 - Cancer $89,416$83,348$99,579 9 - Catastrophic $94,395$97,149$105,010 3M Clinical Risk Groups (CRGs) is a commercially-available diagnosis grouper that creates clinically-relevant, mutually-exclusive risk groups that are ranked according to financial risk

8. © 2012 Denver Health Tier 2.0 Algorithm Tiering 2.0 Adults CRG’s are primary basis for tier assignment Utilization history may override CRG- Assigned tier N=3900 PBPY=$45,574 N=5503 PBPY=$15,698 N=34,245 PBPY=$4148 N=79,247 PBPY=$1289

9. © 2012 Denver Health Tiering 3.o Algorithm Phase 3 – Re-evaluated/optimized CRG assignments to tiers – Re-tooled method of incorporating utilization & clinical lab values Ex. Ran frequencies of diabetic patients with A1c>9/recent inpatient utilization by CRG; used historical data to assess spending over time to determine high opportunity patients

10. © 2012 Denver Health Tier# of PatientsAvg Chrgs 8/10 - 8/11 Avg IP StaysAvg Chrgs 8/11 - 8/12 Avg IP StaysAvg Chrgs 8/12 - 8/13 Avg IP Stays 1 38$8590.00$5,9870.18$6,4790.13 2 1,367$6,8530.07$12,2740.16$13,2080.12 3 197$30,8000.61$39,6780.62$34,5870.56 4 269$67,9591.70$52,4041.07$81,6150.89 Total1,871$18,0380.36$20,8020.34$25,1570.28 TierCRGStatus# of PatientsAvg Chrgs 8/10 - 8/11 Avg IP StaysAvg Chrgs 8/11 - 8/12 Avg IP StaysAvg Chrgs 8/12 - 8/13 Avg IP Stays 1 38$8590.00$5,9870.18$6,4790.13 2 1 - Healthy1$1,6430.00$9,5200.00$32,0901.00 3 - Single Minor Chronic Disease1$3,2950.00$00.00$4,8470.00 4 - Minor Chronic Disease in Multiple Organ Systems1$4,5500.00$00.00$7100.00 5 - Single Dominant or Moderate Chronic Disease430$3,8450.04$6,6220.08$10,8890.10 6 - Significant Chronic Disease in Multiple Organ Systems 915$7,8200.08$14,6820.20$14,1830.13 8 - Dominant, Metastatic and Complicated Malignancies 11$31,5680.36$11,4670.18$5,1650.00 9 - Catastrophic Conditions8$25,3020.50$45,2140.38$37,6370.38 3 197$30,8000.61$39,6780.62$34,5870.56 4 269$67,9591.70$52,4041.07$81,6150.89 Total 1,871$18,0380.36$20,8020.34$25,1570.28 TierCRGStatusBase CRGAvg Chrgs 8/10 - 8/11 Avg IP StaysAvg Chrgs 8/11 - 8/12 Avg IP StaysAvg Chrgs 8/12 - 8/13 Avg IP Stays 1 $8590.00$5,9870.18$6,4790.13 21 - Healthy $1,6430.00$9,5200.00$32,0901.00 3 - Single Minor Chronic Disease $3,2950.00$00.00$4,8470.00 4 - Minor Chronic Disease in Multiple Organ Systems $4,5500.00$00.00$7100.00 5 - Single Dominant or Moderate Chronic Disease $3,8450.04$6,6220.08$10,8890.10 6 - Significant Chronic Disease in Multiple Organ Systems 6141 - Diabetes and Other Dominant Chronic Disease $62,1051.00$84,3933.00$8030.00 6143 - Diabetes and Other Moderate Chronic Disease $11,5420.16$22,2560.37$12,1360.15 6142 - Diabetes and Asthma$8,8220.08$11,0390.12$23,0450.20 6145 - Diabetes and Other Chronic Disease Level 2 $6,2420.11$11,3590.16$10,8770.11 6144 - Diabetes and Hypertension$5,9190.03$10,6120.12$13,9380.12 6270 - Two Other Moderate Chronic Diseases$1,0660.00$3,9400.00$2,4200.00 8 - Dominant, Metastatic and Complicated Malignancies $31,5680.36$11,4670.18$5,1650.00 9 - Catastrophic Conditions $25,3020.50$45,2140.38$37,6370.38 3 $30,8000.61$39,6780.62$34,5870.56 4 $67,9591.70$52,4041.07$81,6150.89 Total $18,0380.36$20,8020.34$25,1570.28 Tiering Challenge Identifying Potential Tier Promotion

11. © 2012 Denver Health Insights/Challenges Interdisciplinary communication is challenging Using big data effectively is an art Financially-oriented (early) algorithms were not clinically useful/accepted; Clinical information alone is inadequate Combined financial/clinical approaches have worked best Integrating social determinants of health would be desirable Transparency helped acceptance of population health approaches Front-line, provider access to reports are key Productivity imperatives/financial disincentives are barriers

12. © 2012 Denver Health Disclaimers & Acknowledgements This presentation was made possible by Grant Number 1C1CMS331064 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. All results are preliminary and proprietary, do not reproduce without permission