Transcript Quality Management and Technology Assessment

Pay for Performance:
Experiences Within An Integrated Delivery System
Jessica C. Dudley, M.D.
Chief Medical Officer
Brigham and Women’s Physicians Organization
[email protected]
March 4, 2009
Key points
 P4P Contracts have begun to engage physicians around addressing
quality and efficiency…but there are limitations.
 The intense expansion of medical knowledge and technology are
major contributors to rising costs, but provide us an incredible opportunity
to diagnose and treat conditions previously unrecognized or untreatable.
 The electronic medical record is a critical tool in providing physicians
with the best available information about an individual patient and is key
to improving efficiency and effectiveness of care.
 Data and reporting are essential for measurement of performance;
showing variation vs. one’s peers is an effective means to engage
physicians.
 Care reimbursement models continue to evolve, and alternative
payment models which support (and reward) quality and efficiency of
care delivery will need to be developed.
2
Agenda
 Partners Healthcare System (PHS) and Brigham and
Women’s Physicians Organization (BWPO)
 Pay for performance (P4P)
– Medical management and P4P at PHS and BWPO
 Efficiency: Pharmacy example
 Quality: Diabetes example
 Process: E-Prescribing example
 Future
– CMS PQRI and VBP
– Other
3
Partners HealthCare: An Integrated Delivery System
Dana-Farber/
Partners Joint
Venture
NewtonWellesley
Health Care
System, Inc.
NewtonWellesley
Hospital,
Inc.
Two Physicians
Appointed by Partners
Partners HealthCare
System, Inc.
Brigham
And
Women’s/
Faulkner
Hospitals
The
Brigham
and
Women’s
Hospital,
Inc.
Faulkner
Hospital,
Inc.
The
Massachusetts
General
Hospital
The
General
Hospital
Corporation
North Shore
Medical
Center, Inc.
Partners
Community
HealthCare,
Inc.
 Founded in 1994, shortly
after the founding of
Partners.
 PCHI is the provider
network for Partners.
 Intentionally given entity
status to assure MD voice
and build trust
4
Eastern Massachusetts PCHI Overview
100 miles
75 miles
PHS Market Share Data:
Adult IP Admissions: 22% (1)
PCPs: 23% (2)
(1)
Source: Massachusetts Division of Healthcare Finance and Policy; Ages 0-17 excluded.
(2)
Sources: Folios, Partners Corporate Provider Master, PCHI
5
Network Composition
Partners Community Healthcare, Inc
~6,337 Total MDs
Primary Care: ~1,162
Academic: ~
419
Specialist: ~ 5,175
Community:
~743
Community:
~1,879
Academic:
~3,296
Total: 2,622
More tightly
aligned
PHS Community Hospital PHOs:
1,013
Integrated Practices:
233
Less tightly
aligned
Affiliated Groups & PHOs::
1,376
6
Components of a Clinically Integrated Network
1. Common practice standards and protocols to govern treatment.
– Uniform across the network and across contracts
– Developed and/or implemented via collaboration among MDs (PCPs and
specialists).
2. Programs to monitor and control utilization and ensure quality.
– Rank and file MDs are aware of programs/goals and can articulate organization’s
approach to quality/efficiency.
3. Measurable outcomes that demonstrate efficiencies.
– Regular evaluation and reporting back to MDs/hospitals
4. Incentives/remedies to modify practice patterns and ensure compliance.
– Meaningful financial incentives/penalties (payer or internal)
5. Significant investment in infrastructure
– Support development/management of clinical programs
6. Common electronic medical record
7
Components of a Clinically Integrated Network
Common
electronic
medical
record
Common
Practice
Standards
and
Protocols
Programs to
monitor &
control
utilization and
ensure quality
Clinically
Integrated
Network
Significant
investment in
infrastructure
Incentives &
remedies to modify
practice patterns &
ensure compliance.
Measurable
outcomes that
demonstrate
efficiencies
The elements
that define a
clinically
integrated
network are the
same elements
that will improve
performance and
patient care
quality
8
Agenda
 Partners Healthcare System (PHS) and Brigham and Women’s
Physicians Organization (BWPO)
 Pay for performance (P4P)
– Medical management and P4P at PHS and BWPO
 Efficiency: Pharmacy example
 Quality: Diabetes example
 Process: E-Prescribing example
 Future
– CMS PQRI and VBP
– Other
9
Evolving Reimbursement and Care Models
PAYMENT METHODOLODY
Full
Capitation
Closed System
SubCapitation
Team-Based Care
Case Rates
Disease Management
P4P
(Robust)
EMR
P4P
(“Lite”)
Fee-forService
Registries
Non-MD Clinicians
Solo MD
Practices
Group
Practices
Multi-Specialty
Group Practices
Integrated
Delivery System
STAGE OF EVOLUTION
Slide used with permission of Thomas H. Lee, MD, of Partners HealthCare System
Clinic Model
10
Components Of P4P Programs
Component
Choices

Payment or withhold needs to be large enough to provide incentive to
physicians
– Withhold pool can be significant at practice or system level but at the
provider level the amount of money can be very small
– Timing of withhold settlement impacts the link between the performance
and return

Efficiency targets – goal of lowering costs
– Prescribing generic medication
– Ordering radiology exams that impact clinical decisions
Quality goals – goal of improving health outcomes
– Targeted diseases (e.g. diabetes, cardiovascular disease)
Process goals – goal of changing status quo behaviors or instituting new processes
to improve quality of care
– Electronic prescribing
– Testing targets (e.g. number of eligible patients w/ mammogram)
Incentives
Targets


Measurement



Data source: claims vs. clinical record vs. patient reports
Adjustments: severity, socioeconomic status
Group vs. individual physicians
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Major Target Areas in Partners P4P
Contracting (Phase 1)
Hospitals
Physicians
 Hospital use (and type)
 Hospital use
 Radiology
 Pharmacy
 Computer order entry
 Radiology
 JCAHO cardiac quality
measures
 Electronic record
adoption
 Diabetes/Asthma/
Chlamydia screening
12
Slide used with permission of Thomas H. Lee, MD, of Partners HealthCare System
Community PCP EMR Adoption
100%
Community PCP EMR Adoption TrendE
80%
60%
40%
20%
0%
2003
2004
2005
Live
2006
2007
Implementing
Data as of December 31, 2007.
Slide used with permission of Thomas H. Lee, MD, of Partners HealthCare System
13
New Major Target Areas in Partners P4P Contracting (Phase 2)
Hospitals
 Hospital use (and type)
 Radiology
► Safe medication administration
systems (e.g., eMAR, smart
pumps)
 JCAHO cardiac quality
measures
► NSQIP/IHI
► Patient experience of care
(HCAHPS)
► End of life care
Physicians
 Hospital use
 Pharmacy
 Radiology
► Electronic record effective use
(electronic prescribing, problem
list accuracy)
► Diabetes outcomes (LDL, BP,
HbA1c)
► Patient experience of care
► End of life care
► Shared decision making
► High risk patient identification
and referrals
The contract goals are becoming more meaningful – and
that is only possible because of the progress with EMR and
other systems achieved thus far.
Slide used with permission of Thomas H. Lee, MD, of Partners HealthCare System
14
Overview
2009 Summary Of BWPO Physician P4P Programs
P4P Goal
Efficiency:
• Pharmacy
• Radiology
• Inpatient
Quality:
• DM
• HTN
• CVD
BWPO Medical Management Program
• Prescribe generics and lower cost brand drugs where appropriate
• Order appropriate imaging tests when necessary for diagnosis
management
• Encourage appropriate “site of care” for individual patients
• Programs that identify and support physicians in
management of patients with targeted diseases
• Case Management for patients at risk for readmission
• Pharmacy management for targeted patients
Process:
• E-RX
• End of Life
• Shared Decision
• E-Prescribing Training
• Advanced directive education
• Distribution of patient education materials
15
Efficiency: Pharmacy Example
Annual cost differential: prescribing a generic drug can provide a
patient (and the system) over a four fold cost savings to the patient
and a ten fold overall cost savings
co-pay
additional cost
$1,200
$1,000
$800
$468
$600
$400
$540
$200
$0
$120
$0
Lexapro
citalopram
16
Efficiency: Pharmacy Example
Problem: What happens when we don’t get it right the first time?
Cost Barrier $45
co-pay
Mrs. Jones is a
50 y.o. female.
Newly diagnosed
with depression.
Rx Lexapro
No
Fill
Access Barrier Prior
Auth Required
Prescribed by
Psychiatrist
Back to
PCP
Rx –
citalopram $10
copay
Goal: To influence MDs behavior so they “write right”
the first time.
Fill
17
BWPO PRIMARY CARE PRESCRIBING
Pharmacy:
BWPO Primary Care Prescribing Policy
POLICY
Efficiency: Pharmacy Example
“It is the policy of Brigham and Women’s Primary Care
to first prescribe a generic or over the counter (OTC)
drug if available. When there are no Generic or OTC
drugs available, or if there is a documented
generic/OTC failure, physicians will work with patients
to find an appropriate alternative.”
18
Efficiency: Pharmacy Example
Physician Education Approach: Adult Therapeutic Grid
 Physician Education
− Target a sub-set of most frequently prescribed drug classes.
− Clinical review of each class to support Therapeutic Effectiveness (PCHI Outpatient
Drug Management Committee).
− Identify lower cost brand and generic alternatives.
− Develop and disseminate PCHI Therapeutic Grid with supporting Prescriber and
Patient Education.
Therapeutic Class
First Line
Formulary
SSRI's fluoxetine
citalopram
paroxetine
Second Line
Costs*
Third Line
Formulary
Costs*
Zoloft
$79
$38
$68
Paxil CR
Prozac Weekly
$85
$104
Aciphex
$137
Nexium
Prevacid
$140
$137
$68
Prilosec OTC
$18
COX IIs
Costs*
$12
Proton Pump Inhibitors om eprazole
NSAIDs ibuprofen
Formular
Protonix
$128
$9
diclofenac
$25
Naprelan
$124
indom ethacin
$9
etodolac
$34
Mobic
$120
naproxen
$9
nabum etone
$61
piroxicam
sulindac
$9
$14
Celebrex
$90
*Costs based upon average cost of a 30 days supply for all dosages, unless otherwise indicated. AWP/MAC
pricing
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Efficiency: Pharmacy Example
Point of Care: Optimal Approach achieved through use of EMR
Support providers at time of prescribing, guiding them to most efficient and cost
effective Rx for specific patient based on their insurance or lack thereof.
40 y.o.
female with
dyspepsia
PCP
enters
Rx Nexium
LMR identifies
Nexium as
“red”
Select from
Alternatives
Rx –
omeprazole
No
Rx
Fill
20
Efficiency: Pharmacy Example
Point of Care Supports Efficient Prescribing and Promotes Quality Care
Through Real Time Decision Support
Efficiency: Pharmacy Example
Point of Care Supports Efficient Prescribing and Promotes Quality Care
Through Real Time Decision Support
Efficiency: Pharmacy Example
% Generic - By PCP (Example Of A Report For One BWPO Practice)
• Average BWPO % Generic is 81.76% v. Practice average of 78.41%
• Patients who pay generic vs brand co-pays save an avg. of $420/year
• Studies show that high drug costs adversely impact medication adherence
100%
78.41% 80.00%
90%
80%
71.37%
73.33% 75.17%
76.43%
81.76% 82.56% 82.78%
83.91%
84.46% 84.96%
83.92%
70%
60%
50%
40%
30%
20%
10%
0%
1
2
3
4
5
6
PCP % generic
• Pharmacy claims data Jan 08 – Jun 08
7
8
9
10
11
12
13
Avg. BWPO PCP % generic
23
Efficiency: Pharmacy Example
BWPO Pharmacy: Use Of Generic Drugs Has Steadily Risen
BWPO pharmacy trends, q106-q408
% generic prescriptions written
74.00%
72.00%
70.00%
68.00%
66.00%
64.00%
62.00%
60.00%
58.00%
56.00%
54.00%
Q106
Q206
Q306
Q406
Q107
Q207
Q307
Q407
Q108
Q208
Q308
Q408
% Generic
24
Quality: Diabetes Example
Opportunities For Improvement In Getting Patients To Target
% of BWPO P4P Patients with diabetes at target for LDL, A1C*, BP, and all three
90%
78%
80%
70%
60%
54%
50%
40%
36%
30%
20%
20%
10%
0%
LDL < 100
Source: Matrix (CDR+Claims) as of 12/5/08
Missing Data counted as “not at target”
A1c < 9
BP < 130/80
All 3
25
Quality: Diabetes Example
Quality: Variation In LDL Target Achieved By Practices
Percent of patients with CVE or diabetes at LDL target
90%
80%
60%
62%
Practice N
Practice L
Practice D
56%
Practice K
Practice C
55%
Practice J
Practice B
55%
Practice I
47%
54%
Practice H
47%
54%
Practice G
46%
51%
Practice F
45%
Practice A
50%
50%
Practice E
60%
56%
Practice M
70%
40%
30%
20%
10%
0%
Source: Matrix (CDR+Claims) as of 12/5/08
LDL Compliant: LDL Drawn in 2008 with value less than 100
26
Quality: Diabetes Example
BWPO PCP “Action” Reports: Inform Physicians about Patients and
Offers Provider Support for Follow-Up
27
Quality: Diabetes Example
There is no “one size fits all” solution…but using electronic
communication with linkage to EMR improves efficiencies.
Results from the PCP “Action” Reports
 PCPs Returned the Reports
 Reports alone are not an effective tool for enrollment of patients in programs
external to PCP office
 Only 5% of eligible patients were signed up for LDL titration program via
report
 Further education on protocol followed by direct email outreach with
communication of eligible patients along with LDL titration protocol to PCPs
resulted in much higher interest in enrollment.
 Preliminary results reveal approx 60% enrollment rate
Next Steps
 List Management Software
 Electronic communication
 Links from the reports directly into the patients medical record
 Use electronic survey communication to capture physician follow-up
orders
28
Process: E-Prescribing
E-prescribing Adoption
 E-Prescribing improves physician efficiency and patient quality
− With ‘favorites” it typically only takes a few clicks to prescribe and renew
prescriptions
− Prescriptions are accurate and clear, no more deciphering physician handwriting
− System can provide real time decision support: system can warn of drug/drug
interactions, allergies listed in patient record, lower cost alternatives
 BWPO developed a program that customized the medication module for each
practice and trained physicians on how to efficiently use the system
 Key elements
− Leadership buy in
− Engage “super-user”
− Customize medication module – set up favorites and short cuts
− Customize training – presentations, one-on-one
29
Process: E-Prescribing
E-prescribing: preset “favorites” help physicians quickly prescribe meds
they use most often
30
Process: E-Prescribing
E-prescribing: Real Time Decision Support
31
Process: E-Prescribing
BWPO E-prescribing Performance improving
Percent of physicians using e-prescribing
100%
91%
90%
80%
2009 Target: 75%
69%
70%
% E-RX
70%
60%
50%
36%
40%
30%
20%
10%
0%
PCP
Q407
Spec
Q408
32
Some shortcomings of P4P
Problem
Process vs.
Outcomes
Too much
vs. too little
Lack of
“fairness”
Description

Focus on achieving process metrics, not always on outcomes
– E.g., testing targets focus on getting the test done, not the results


Work to the target and not beyond
If threshold set too high, some MDs may not see hope of payment

Majority of targets linked to PCP engagement; very few current goals tied to
specialist engagement
Providers at risk for things they can’t control

–
–
Confusion



Poor patient adherence
Varying severity of illness
Different payors have their own programs, with their own targets
Not all patients included, but physician practice doesn’t change by payer
Often difficult to measure with existing data resources
33
Agenda
 Partners Healthcare System (PHS) and Brigham and Women’s
Physicians Organization (BWPO)
 Pay for performance (P4P)
– Medical management and P4P at PHS and BWPO
 Efficiency: Pharmacy example
 Quality: Diabetes example
 Process: E-Prescribing example
 Future
– CMS PQRI and VBP
– Other
34
CMS: PQRI and Value Based Purchasing
 CMS Physician Quality Reporting Initiative
–
Current model is “bonus” for “reporting” on selected quality metrics and
demonstration of E prescribing
–
Physician participants to date have experienced many challenges and few have
received anticipated payments
–
Anticipate will become “required” for payment, not “bonus” going forward
 CMS Issue Paper December 2008 with plans to transition from FFS to “Value-Based
Purchasing”
−
Acknowledging that fee for service NOT effective for ensuring quality and efficiency
−
Goal of providing right care for every person every time
−
Promote practice of evidence based medicine (msmt, financial incentives, public reporting)
−
Decrease fragmentation and duplication of care (episodes of care, smoother transitions)
−
Effective management of chronic diseases (focus on prevention, preventable admissions,
advanced care planning, end of life care)
−
Accelerate adoption of HIT
−
Empower consumers to make value based health care choices
35
Some Conclusions from P4P
 Take risk on things you can control
 Engage physicians in the process
 Leverage EMR technology –
–
Creates efficiencies in engaging physicians at point of care
–
Provides more comprehensive information about individual patients
–
Deploys clinical decision support
–
Captures information for measurement and reporting
 Aim for concordance of measures across health plans
 Be proactive in designing systems
–
Approach may vary by measure
–
Understand your organization’s strengths and weaknesses
 Measuring the impact of a program can be a challenge
–
Process vs. outcome
–
Quality vs. efficiency
 Modify programs as you learn more
36
A recap
 P4P Contracts have begun to engage some physicians around addressing quality
and efficiency…but financial risk is minimal and affects primarily primary care
physicians and not specialists.
 The intense expansion of medical knowledge and technology and the
accompanying rising costs demand changes in the traditional models of individual
providers caring for individual patients under a FFS system and support more
team based care with alternative payment models which support quality and
efficiency of care delivery.
 The electronic medical record is a critical tool in providing physicians with the best
available information about an individual patient and is key to improving
efficiency and effectiveness of care. Physicians need to adopt the use of EMRs
and will need to be trained in effective use.
 Data and reporting are essential for measurement of performance; showing
variation vs. one’s peers is an effective means to engage physicians.
 Patients will need to become more engaged in their health care management and
decision making with increased transparency.
37