Transcript Tim Ferris Presentation - Alliance for Health Reform

The Engaged Provider Response to
the Current Health Care Policy
Environment
July 18, 2011
Timothy G Ferris, MD, MPH
Mass General Physicians Organization, Medical Director
Associate Professor, Harvard Medical School
The Engaged Doctor’s Dilemma

Health care costs are rising too rapidly

We have been through this before
 Healthy skepticism that the next big idea
from an insurance company is actually
going to solve this problem.

Physicians remain unsure of what
reform will bring
Population
Management
Episodes of Illness
Inpatient and
Outpatient
Encounters
 Multiple approaches in commercial, state,
and federal payers
 Uncertainty in payment reforms leaves the
engaged provider with little direction regarding
how to get started

So what is the engaged provider to do?
 Whatever the new payment system, there are some clear directional indicators:
 Change focus - from units to episode and populations
 Move forward - move forward with the things that I know have been shown to improve
outcomes and/or reduce costs.
 Always improve - create incentive structure that rewards continuous innovation
2
Engaged Provider Tactics
Longitudinal Care
Primary Care
Episodic Care
Specialty Care
Patient portal / physician portal
Access to
care
Hospital Care
Optimize site of care
Extended hours / same day appointments
Expanded virtual visit options
Reduced low acuity
admissions
Defined process standards in priority conditions
(multidisciplinary teams, registries)
Re-admissions
Design of
care
High risk care
management
Required patient decision
aids
Provide 100% preventive
services
Appropriateness
Hospital Acquired
Conditions
Hand-off standards
Continuity Improvements
EHR with decision support and order entry
Incentive programs (recognition, financial)
Internal variance reporting / performance dashboards
Measurement
Publicly reporting of quality metrics: clinical outcomes, satisfaction
Costs / population
3
Costs / episode
Chronic Conditions – MGH Medicare Demo
MGH Demo
•
Medicare selected MGH to participate in a 3-year
demonstration project focusing on high-cost
beneficiaries in 2006
•
Success validated in 2010 (RTI evaluation)
•
Contract renewed through 2012
•
Expanded to Brigham and Women’s and North
Shore Medical Center

Average number of medications = 12.6
Average annual hospitalizations = 3.4
Average annual costs = $24,000
Payment model similar to proposed shared savings for ACOs




Paid monthly fee based on number of enrolled patients
Required to cover costs of program +5%
Gainsharing if savings greater than cost +5%
Success determined using prospective matched comparison
group
http://www.massgeneral.org/about/newsarticle.aspx?id=2531
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10% of Medicare patients account for
nearly 70% of spending
Enrolled 2,500 highest cost Medicare patients with total
annual costs of $68 M




Opportunity
Chronic Conditions – MGH Medicare Demo
Results from Independent Evaluator (RTI)

12 care managers embedded in primary care practices
 Coordinate care; point person for acute issues
 Identify patients at risk for poor outcomes
 Facilitate communication when many caregivers involved

Key characteristics
 Care managers have personal relationships with patients
 Care managers work closely with physicians
 All activities supported by health IT (universal EHR, patient tracking, home
monitoring)

Successful Outcomes
 Hospitalization rate among enrolled patients was 20% lower than comparison*
 ED visit rates were 25% lower for enrolled patients*
 Annual mortality 16% among enrolled and 20% among comparison

Successful Savings
 7.1% annual net savings (12.1% gross) for enrolled patients
 For every $1 spent, the program saved at least $2.65
*Based on difference in differences analysis
5
Health IT – Integrated Decision Support for Imaging
• Radiology utilization management systems
Scatterplot of outpatient CT examination volumes (y-axis) per calendar quarter
(x-axis) represented by red diamonds.
Sistrom C L et al. Radiology 2009;251:147-155
©2009 by Radiological Society of North America
MGH Internal Physician Quality Measures
http://www-958.ibm.com/software/data/cognos/manyeyes/visualizations/mgh-quality-meas-overview-1209
7
MGH Internal QI Program Measures
Hand Hygiene / MSRA
EMR Use (for Notes)
HH and MRSA Rates
Before contact rates
After contact rates
MRSA Rate
100%
2.50
90%
80%
2.00
1.95
1.79
70%
1.51
60%
1.52
1.50
1.33
1.33
50%
1.22
1.21
1.25
1.33
1.12
1.08
1.09
1.18
40%
1.08
1.03
0.99
1.00
1.00
0.96
0.88
0.82
30%
0.81
0.66
0.61
0.50
0.60
20%
10%
2002
2003
2004
2005
2006
2007
Quarter 3
Quarter 2
Quarter 1
Quarter 4
Quarter 3
Quarter 2
Quarter 1
Quarter 4
Quarter 3
Quarter 2
Quarter 1
Quarter 4
Quarter 3
Quarter 2
Quarter 1
Quarter 4
Quarter 3
Quarter 2
Quarter 1
Quarter 4
Quarter 3
Quarter 2
Quarter 1
Quarter 4
0.00
Quarter 3
0%
2008
Radiology Turn Around Times
Top Box %
H-CAHPS Performance
83.0%
82.5%
82.0%
81.5%
81.0%
80.5%
80.0%
79.5%
79.0%
78.5%
Q2
Q1
11
11
10
2011 P4P Target
10
QI Target
Q4
10
10
09
09
09
09
2010 Avg.
Q3
Q2
Q1
Q4
Q3
Q2
Q1
8
Results
2011 YTD (prelim)
Engaged Provider Tactics: HITECH
Meaningful
Partnership
Bundled
Medical Home
Payment
Use
for Patients
Longitudinal Care
Episodic Care
Primary Care
Specialty Care
Hospital Care
Patient portal / physician
Patient portal / physician
Patient portal / physician portal
portal
portal
Access to
care
Optimize site of care
Extended hours / same day
Extended hours / same day
Extended hours / same day appointments
appointments
appointments
Reduced low acuity
admissions
virtualExpanded
visit options
Expanded virtualExpanded
visit options
virtual visit options
Defined process standards in priority conditions
(multidisciplinary teams, registries)
Design of
care
High risk care management
Required patient decision aids
Provide 100% preventive
services
Appropriateness
Re-admissions
Hospital Acquired Conditions
Hand-off standards
Continuity Improvements
EHR with decision support
EHR with decision
support
and order
entry and order entry
EHR
with decision
support
and order entry
Incentive programs (recognition, financial)
Internal variance reporting /
Internal varianceInternal
reporting
/ performance
dashboards
variance
reporting
/ performance dashboards
performance dashboards
Measurement
Publicly reporting of quality metrics: clinical outcomes, satisfaction
Costs / population
9
Costs / episode
Closing Thoughts
 Doing all this will take quite a while – the stakeholders will need to
be a little patient
 How do we incent providers to do these other things?
 Gold card status for engaged providers resulting in lower administrative
costs for payers and providers
 This presentation addressed only the engaged provider side of a two
party relationship:
 Incentives for patients to be judicious consumers of health care would
be a powerful complementary set of policies
 Type types of innovation
 Adopting and implementation of ideas known to be effective (i.e. “new”
processes)
 Development and testing of new technology and processes not yet
known to be effective
10