Juliet L. Rogers, PHD, MPHAssistant Professor, Health Management & PolicyUniversity of Michigan School of Public Health

The Challenges and Opportunities of Scaling Integrated Wellness Models

Creating a Space for Wellness: Integrative Health in Primary CareMarch 16-17, 2017

• Starting programs in large practices or health systems may be easier than sustaining them over time

• Greatest obstacles are payer dynamics and financial vulnerability when pool of resources is reduced

• Greatest opportunities are in shifts to value-focused care, creative new networks, consumer dynamics

• Framework for generating support for delivery of integrated care models at system scale

Main Points

Current Challenge: Uncertainty

• ACA repeal or replacement• Shift to value-based care in question• Focus on system growth will remain• Payment model drives model of care

Regardless of state/federal dynamics, patients and consumers are bearing more financial burden for care and looking for options

Mixed Messages

Promise of the Affordable Care Act: • National Prevention Fund • Economic incentives for ACOs and for establishment

of patient-centered medical homes

Challenges Remain:• Conventional, third-party insurance payer model –

low touch, high tech, high margin • Integrative models - high touch, low tech, low margin

Reality of the Payment ModelWe are still incentivizing procedures and products over prevention and wellness.

Spent on existing, chronic conditions Spent on prevention & wellness

Toward Sustainability• Signature differentiation in the healthcare marketplace• Community of practitioners aligned with the vision • Credibility with the traditional physicians• Subsidization by higher-margin, core services • Adequate resources and funding

Sources: Bravewell Clinical Network; Cleveland Clinic Center for Functional Medicine; Blue Cottage Consulting; Zollman C, Vickers A. ABC of complementary medicine: complementary medicine in conventional practice. Br Med J 1999;319:901-4.

Overcome Resistance to Change • Joint programs with conventional departments• Low overhead• Hybrid model: insurance + program fees + retainer• Experiential, educational, content-based programs • Apprenticeship, education, and training

Sources: Bravewell Clinical Network; Cleveland Clinic Center for Functional Medicine; Blue Cottage Consulting; Zollman C, Vickers A. ABC of complementary medicine: complementary medicine in conventional practice. Br Med J 1999;319:901-4.

Used with permission granted 2/27/2017; Source: Baechler, Courtney, Allina Health

Opportunity to Align Values at Scale

Opportunity to Align Values at Scale

“Kaiser is an integrated system in which the hospital, health plan and physician group are all under one umbrella, making wellness and prevention a high priority for the entire organization.”

- Source: Kaiser Permanente spokesperson, San Diego Business Journal, 1/16/2016

Practitioners in Integrative Model

29 Centers surveyed 2011 Bravewell Collaborative Survey; Reported in Global Adv Health Med. 2012;1(3):18-94.

Models of Successful IntegrationBehavioral Health & Wellness

Southcentral Foundation NUKA System of Care• Serves 60,000 Alaska Native and American Indian people • Multidisciplinary teams provide integrated services in primary care

centers and the community, coordinating with a range of services• Tribal & traditional services, chiropractic, massage, acupuncture,

family wellness warriors• Reduction in ED visits, hospitalization, and specialty care visits

Sources: Southcentral Foundation website; Slideshare; SCFNuka.com website

Southcentral FoundationNUKA System of Care

CUSTOMER OWNERSHIP CULTURALLY-RESPECTFUL CARE COMPASSIONATE CARE SAME-DAY ACCESS TEAM-BASED

An entire team is dedicated to each patient’s wellness to ensure convenient experience and access to a panel of experts94% satisfaction with respect for cultures/traditions36% reduction in hospital days42% reduction in urgent/emergency care services58% reduction in visits to specialist clinicsSources: Southcentral Foundation website; Slideshare; SCFNuka.com website

Southcentral FoundationNUKA System of Care

Credit: NBBJ for Southcentral Foundation (Alaska) via www.nbbj.com

Models of Successful IntegrationNutrition & Wellness

Cleveland Clinic's Center for Functional Medicine• 14,000 visits projected for 2017• 16 exam, 2 behavioral consult rooms, group visits, lab• Patients spend an hour with a physician, an hour with a nutritionist

and 15 to 30 minutes with a health coach• Bring functional medicine and nutrition into educational curriculum• Working with insurance companies to redefine payment model

*CCCFM is not an integrative health center, it is a Center for Functional Medicine. However, the lessons in delivering care at scale and integrating several practitioner types is applicable to Integrative Health and Medicine.

Sources: Lydia Coutre “Cleveland Clinic’s holistic center is on rapid ascent”, Crain’s Cleveland Business, Jan 22, 2017.; Eric Goldman “Facing Huge Demand, Cleveland Clinic Doubles Its Functional Medicine Center” Feb 18 2016, Holisticprimarycare.net

Cleveland Clinic's Celia Scott WeatherheadCenter for Functional Medicine

The Center includes a laboratory, telemedicine suites, meeting rooms, self-led educational programming , shared medical appointments• By and large, insurers have been friendly toward CFM • 95% of the physician office visits covered by insurance• 50% of the nutrition visits covered by insurance• Office visits are billed as Level 4 or 5 internal medicine visits

*CCCFM is not an integrative health center, it is a Center for Functional Medicine. However, the lessons in delivering care at scale and integrating several practitioner types is applicable to Integrative Health and Medicine.Sources: Lydia Coutre “Cleveland Clinic’s holistic center is on rapid ascent”, Crain’s Cleveland Business, Jan 22, 2017.; Eric Goldman “Facing Huge Demand, Cleveland Clinic Doubles Its Functional Medicine Center” Feb 18 2016, Holisticprimarycare.net

Cleveland Clinic's Celia Scott WeatherheadCenter for Functional Medicine

• By and large, insurers have been friendly toward CFM

• 95% of the physician office visits covered by insurance

• 50% of the nutrition visits covered by insurance

• Office visits are billed as Level 4 or 5 internal medicine visits

*CCCFM is not an integrative health center, it is a Center for Functional Medicine. However, the lessons in delivering care at scale and integrating several practitioner types is applicable to Integrative Health and Medicine.Sources: Lydia Coutre “Cleveland Clinic’s holistic center is on rapid ascent”, Crain’s Cleveland Business, Jan 22, 2017.; Eric Goldman “Facing Huge Demand, Cleveland Clinic Doubles Its Functional Medicine Center” Feb 18 2016, Holisticprimarycare.net; The Institute for Functional Medicine Survey of Functional Medicine Practices, 2016.

Models of Successful IntegrationBehavioral Health

Southcentral Foundation NUKA System of Care• Serves 60,000 Alaska Native and

American Indian people • Multidisciplinary teams provide

integrated services in primary care centers and the community, coordinating with a range of other services

• Tribal & traditional services, chiropractic, massage, acupuncture, wellness warriors

• Reduction in ED visits, hospitalization, and specialty care visits

Nutrition & Wellness

Cleveland Clinic's Center for Functional Medicine• 2017 visit projection: 14,000• 16 exam and 2 behavioral consult rooms• Patients spend an hour with a physician,

an hour with a nutritionist and 15 to 30 minutes with a health coach

• Bring functional medicine and nutrition into educational curriculum

• Working with insurance companies to redefine payment model

Sources: Southcentral Foundation website; Slideshare; Lydia Coutre “Cleveland Clinic’s holistic center is on rapid ascent”, Crain’s Cleveland Business, Jan 22, 2017.; Eric Goldman “Facing Huge Demand, Cleveland Clinic Doubles Its Functional Medicine Center” Feb 18 2016, Holisticprimarycare.net

REVIEW

Overcome Resistance & Become Sustainable• Signature differentiation in the healthcare marketplace• Community of practitioners aligned with the vision • Credibility with the traditional physicians• Joint programs with conventional departments• Subsidization by higher-margin, core services • Low overhead• Adequate resources and funding• Hybrid model: insurance + program fees + retainer• Experiential, educational, content-based programs • Apprenticeship, education, and trainingSources: Bravewell Clinical Network; Cleveland Clinic Center for Functional Medicine; Blue Cottage Consulting; Zollman C, Vickers A. ABC of complementary medicine: complementary medicine in conventional practice. Br Med J 1999;319:901-4.

REVIEW