Pay For Performance: A Better Environment for …Quality – Cost Relationship Metro Primary Care,...
Transcript of Pay For Performance: A Better Environment for …Quality – Cost Relationship Metro Primary Care,...
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Pay For Performance: A Better Pay For Performance: A Better Environment for Quality in Environment for Quality in
Health CareHealth CareGeorge Isham, M.D., M.S.George Isham, M.D., M.S.
Chief Health OfficerChief Health OfficerHealthPartners, Minneapolis, MNHealthPartners, Minneapolis, MN
Health Information Technology Summit, D.C., September 9, 2005Health Information Technology Summit, D.C., September 9, 2005
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The Healthcare System The Healthcare System The Quality ChasmThe Quality Chasm
Highly variable (and too often unsafe) quality of clinical care
Gaps between evidence and practice
New science takes 17 years to widely incorporate and practice
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The Healthcare System The Healthcare System Some More ProblemsSome More Problems ……
The business model for pharmaceutical companies, device manufacturers, and healthcare services depends on inducing demand for their products and services
Unit pricing (FFS) induces over use of services
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The Healthcare SystemThe Healthcare SystemSome More Problems …Some More Problems …
Asymmetry of information between patients and professionals
Patients do not understand the quality and cost of healthcare services (Quality for consumers is convenience, access and amenities)
Variability in health care performance is often unknown and providers are reluctant to display it
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The Healthcare System:The Healthcare System:A Broken ThingA Broken Thing
Quality Chasm
Uninformed Consumers
Spiraling costs
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HealthPartners’ ApproachHealthPartners’ ApproachMeasure value (Q/C), display it for consumers and reward providers for delivering it
Insist on transparent provider performance reporting for consumers, providers and purchasers
Realign cost and quality for consumers through plan design
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HealthPartners’ ApproachHealthPartners’ Approach
Pay for Performance
Do not pay for catastrophic performance
Support quality improvement
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A large open access network supports choiceSorts providers into two tiersIncludes access to comparative information about providersIncludes provider incentives for quality and cost efficiency
The Distinctions Plan Offers Consumer Incentives to Select High
Value Providers
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The DistinctionsThe DistinctionsSMSM PlanPlanHow HealthPartners Tiers ProvidersHow HealthPartners Tiers Providers
Step 1. Quality & ServiceProviders are scored on quality and service measures.
Step 2. AffordabilityProviders are scored on risk-adjusted total cost of care. The score reflects the combined impact of price, efficiency and utilization management.
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The DistinctionsThe DistinctionsSMSM PlanPlanHow HealthPartners Tiers ProvidersHow HealthPartners Tiers Providers
Step 3. Combined ScoresProviders need to meet both the risk-adjusted total cost of care test and the quality and service test to qualify for the best tier placement
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Quality Quality –– Cost RelationshipCost Relationship
Metro Primary Care, Multi-Specialty and Single Specialty Clinics
0.40
0.60
0.80
1.00
1.20
1.40
1.60
0.8 0.85 0.9 0.95 1 1.05 1.1 1.15 1.2
Cost Index
Qua
lity
Inde
x
Tier 1-High Quality Low Cost
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Quality Quality –– Cost RelationshipCost RelationshipMetro Hospitals
0.40
0.60
0.80
1.00
1.20
1.40
1.60
0.70 0.80 0.90 1.00 1.10 1.20 1.30
Cost Index
Qua
lity
Inde
x
Tier 1-High Quality Low Cost
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Primary Care Report CardPrimary Care Report Card
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Hospital Report CardHospital Report Card
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HealthPartners Quality/Cost HealthPartners Quality/Cost Incentive ProgramsIncentive Programs
Two programs that drive quality improvement:
1. Outcomes Recognition Program2. Pay for Performance Program
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Outcomes Recognition Outcomes Recognition Program (ORP)Program (ORP)
Introduced in 1997Offers bonus rewards to medical groups who achieve superior results26 medical groups in ORP care for 90 percent of our membersBonus pools $100,000 - $300,000
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Pay for Performance ProgramPay for Performance Program
Introduced in 2002 Integrates payment for quality into primary care, specialty and hospital contracts Pay for Performance is part of the market rate – good value for employers and members
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In 2004, HPI will pay up to $16 million in provider reimbursement for quality performance
HealthPartnersHealthPartnersOutcomes Recognition Program Outcomes Recognition Program
and Pay for Performance Programand Pay for Performance Program
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2005 2005 Primary Care MeasuresPrimary Care Measures
60%55%Satisfaction with Appointment Scheduling65%60%Optimal Depression Care63%60%Generic Drug80%75%Assist95%90%Assessment
Tobacco:90%80%Body Mass Assessment30%25%Optimal Diabetes Care
60%55%Optimal Care for Heart DiseaseSuperiorExcellent
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HealthPartnersHealthPartnersOptimal Diabetes Care: Optimal Diabetes Care:
Preventing ComplicationsPreventing Complications
0%
5%
10%
15%
20%
25%
30%
1999 2000 2001 2002 2003
MI, MI, stroke, eye & stroke, eye & kidney problemskidney problems26,000 mbrs with 26,000 mbrs with diabetesdiabetes4,8004,800 @ target for @ target for allallrisksrisks
’04 ORP Target 30%
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Excellent Diabetes Care: Excellent Diabetes Care: Managing All Risk FactorsManaging All Risk Factors
OPTIMAL CAREBlood pressure under 130/85Daily aspirin use“Bad” cholesterol under 130HbA1c at or under 8.0Non smoker
0%10%20%30%40%50%60%70%80%90%
100%
BP ASAUse
LDL HbA1c TobacoFree
Met All
1999 2000 2001 2002 2003
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Average A1c & CAD LDLAverage A1c & CAD LDL
66.5
77.5
88.5
9
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Mea
n A
1c
70
80
90
100
110
120
Mea
n LD
L
A1c CAD LDL-Chol
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Fewer Diabetes ComplicationsFewer Diabetes Complications
0
2
4
6
8
10
12
14
16
18
20
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
Amputations/1,000MI/1,000CABG+PTCA/1,000 New Retinopathy/1000
50
55
60
65
70
75
80
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
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Tobacco ‘Vital Sign’ ImpactTobacco ‘Vital Sign’ Impact
26%
16%
11%
23%
0%
20%
40%
60%
80%
100%
1997 1998 1999 2000 2001 2002 2003
Ask AssistTob Prev 2nd Hand Smoke
40% 40% have quit!have quit!60% 60% more asked!more asked!30% 30% more get help!more get help!50%50% less 2less 2ndnd Hand Hand smoke!smoke!
This means:This means:54,000 people quit 54,000 people quit Each year 250 don’t dieEach year 250 don’t die
MN Prevalence = 21%
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HealthPartners Payment Policy HealthPartners Payment Policy Never EventsNever Events
Patients Should Never Have to Pay for Patients Should Never Have to Pay for a Never Eventa Never Event
As of January 1, 2005:Hospitals report Never Events to HPIHPI denies payment or recoups paymentApplies to hospitals only, not physicians Charges are provider liabilityMember cannot be billed!
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BackgroundBackgroundNever EventsNever Events
In 1999 IOM documented the prevalence of medical errors in hospitals – “To Err is Human.”IOM recommended a mandatory reporting system to ID and improve persistent safety problems
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BackgroundBackgroundNever EventsNever Events
In response in 2002 the National Quality Forum (NQF)
Defined 27 Never Events - things that should never, ever happen Established standards for reporting medical errors
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Some NQF Never EventsSome NQF Never EventsSurgical Events
Wrong surgery, body part or patientRetention of foreign object
Product or DeviceContaminated drugs, devices, biologics
Patient ProtectionInfant discharged to wrong personPatient death associated with disappearance
Care ManagementPatient death or disability
Medication errorStage 3 or 4 pressure ulcers
Environmental EventsPatient death or disability
Wrong gas deliveredBurn while being cared for
Criminal EventsAbductionSexual Assault
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Minnesota’s Adverse Health Minnesota’s Adverse Health Event Reporting LawEvent Reporting Law
Mandated the reporting and systematic tracking of NQF “Never Events”Sponsored by a coalition of hospitals, doctors, nurses, and patient advocatesBold leadership by Minnesota hospitalsPassed May, 2003 and effective July, 2004First in nation – unparalleled transparency
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Adverse Health Events in Adverse Health Events in Minnesota HospitalsMinnesota Hospitals
First public report for period July 1, 2003 – October 6, 2004 *
Surgical 52 eventsProduct or device 4 eventsPatient protection 2 eventsCare Management 31 eventsEnvironmental 9 eventsCriminal 1 event
99 events
*Represents event reports completed during transition period of law
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MN Community MeasurementMN Community Measurement ��
2004 Healthcare Quality Results2004 Healthcare Quality Results
© Minnesota Council of Health PlansAll rights reserved
Do not show, disseminate, or make copies of these materials without permission from the MN Council of Health Plans ([email protected]; 651-645-0099 ext. 12)
Blue Cross and Blue Shield of MinnesotaFirst Plan
HealthPartnersMedica
Metropolitan Health PlanPreferred One
UCare MinnesotaMinnesota Council of Health Plans
MN Medical GroupsNCQA
StratisHealth
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2004 Medical Group Results 2004 Medical Group Results Average, High, Low Rates by MeasureAverage, High, Low Rates by Measure
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Asthma 5
-56
Depress
ion 18
0 Day
s
Ped Im
m Com
bo II
Adol Im
m Combo
II
Well Chil
d 6 Visit
s
Optimal
Diabete
s Care
Contro
lling H
BP
Breast
Cancer S
creen
Cervica
l Can
cer S
creen
Chlamyd
ia Test
16-25
A1c Test
A1c < 8.
0LD
L-Chol
Test
LDL-C
hol <13
0BP Test
BP <130/8
5
Aspirin
Dail
y 40+
Non-S
moker
Renal S
creen
Eye Scre
en
Medical Group Low Medical Group High Overall Average
© Minnesota Council of Health PlansAll rights reserved
Do not show, disseminate, or make copies of these materials without permission from the MN Council of Health Plans ([email protected]; 651-645-0099 ext. 12)
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ICSI (Institute for Clinical ICSI (Institute for Clinical Systems Improvement)Systems Improvement)
A collaboration of 48 medical groups & A collaboration of 48 medical groups & hospital systemshospital systems
Sponsored by six health plansSponsored by six health plans
Established 1993Established 1993
Includes 54 hospitals and medical practices Includes 54 hospitals and medical practices totaling 7100 physicians (2/3rds in MN)totaling 7100 physicians (2/3rds in MN)
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ICSI Member Locations
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MissionMission
The mission of our collaboration is to The mission of our collaboration is to
champion the cause of health care quality champion the cause of health care quality
and to accelerate improvement in the and to accelerate improvement in the
value of the health care we deliver. value of the health care we deliver.
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Crossing the Quality ChasmCrossing the Quality ChasmCommittee’s Conclusion:Committee’s Conclusion:
The American health care delivery system The American health care delivery system is in need of fundamental change. The is in need of fundamental change. The current care systems cannot do the job. current care systems cannot do the job. Trying harder will not work. Changing Trying harder will not work. Changing systems of care will. systems of care will.
To order: www.nap.edu
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Care System
•Redesign of care processes based on best practice•Effective use of information technologies•Knowledge and skills management•Development of effective teams•Coordination of care •Incorporation of performance and outcome measurementsfor improvement and accountability
Supportivepayment and regulatoryenvironment
Organizationsthat facilitatethe work of patient-centered teams
High performingpatient-centeredteams
Outcomes:•Safe•Effective•Efficient•Pt Centered•Timely•Equitable
Adapted from IOM, Crossing the Quality Chasm
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A supportive payment and regulatory environment
(In other words, a non-toxicpayment and regulatory
environment) is a critical requirement for
crossing the quality chasm.