Transcript A Plan for Michigan - Federal Reserve Bank of Chicago

Blue Cross Blue
Shield of Michigan
Taming the
Healthcare Beast:
A Plan for Michigan
Federal Reserve
Bank
March 31, 2009
Presenter: Tom Simmer M.D.
Chief Medical Officer
Overview
• A few facts about health status, healthcare costs, and personal
income in Michigan.
• The Goal: Improve the competitive position of the state of
Michigan for business while supporting access to needed
medical services.
• Provider Partnership Programs improve healthcare delivery
through population based, collaborative initiatives, often
connected with performance-based payment.
• A quick look at results.
2
Michigan Personal Income Falling
Relative to U.S.
Michigan per Capita Income as a Percent of U.S. Per Capita Income
1.25
1.2
122%
1.15
1.1
1.05
1
93%
89%
0.95
0.9
0.85
29 933 937 941 945 949 953 957 961 965 969 973 977 981 985 989 993 997 001 005
9
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2
Source: Department of Treasury calculations from Bureau of Economic Analysis data
3
Source: “Michigan’s Health Care Safety Net: In Jeopardy,” A MHA Special Report
4
Older, fatter, smokier, sicker
2007 Data
Michigan
U.S.
Average
% Change
of U.S.
Average
Median age in years
37.5
36.6
2.5
Obesity prevalence among adults
28.2%
26.3%
7.2
Diabetes prevalence among
adults
8.8%
8.1%
8.6
Smoking prevalence among
adults
21.1%
19.7%
7.1
5
2008 Michigan Health Plan Costs*
Average Annual Cost to Employer Per
Employee
State:
$8,812
Regional: $7,557
National: $7,327
Employer Share
State:
$6,152
Employee Share
State:
$2,660
Regional: $4,904
Regional: $2,653
National: $4,117
National: $3,210
2008 health plan costs according to the annual United Benefit Advisors Health Plan Survey. The survey
included 18,019 employers nationally, 5,283 in a four-state region and 828 in Michigan. United Benefits
Advisors is a national alliance of independent insurance agencies that includes The Campbell Group in Grand
Rapids, BenePro Inc. in Royal Oak, Pappas Financial in Farmington Hills, Saginaw Bay Underwriters in
Saginaw and Employee Benefits Agency in Marquette.
Why haven’t we succeeded in healthcare?
• Lack of Population focus – fee for service / third party
payment system drives increased delivery of services.
• Cottage industry: Physician practices lack capacity to build
information infrastructure and implement lean processes that
are key to improving performance.
• Health plan, rather than delivery system, focus introduces
process variation and re-work, not clinical process improvement.
• Weak primary care foundation misses opportunities for care
coordination and lower cost approaches.
• BCBSM programs are unique in rewarding population-based
improvements in care, strengthening primary care, investing in
infrastructure through large physician organizations, and
reducing variation through lean process improvement across the
delivery systems and across payers.
7
BCBSM Members
Effective Providers
Wellness & Care Management
Michigan
Basics
-Precertification
-Utilization Review
BCBSM Clinical Programs
8
Current Partnering for Value Programs
Physicians
CQIs: Collaborative
Quality Initiatives
Hospitals
Michigan Surgical
Quality Collaborative
PGIP:
Physician Group
Incentive Program
Michigan Bariatric Surgery
Collaborative
Hospital
Incentive
Program
BMC2: BCBSM Cardiovascular Consortium
Angioplasty Collaborative Quality Initiative
(in Participating
Hospital
Agreement)
Michigan Society of Thoracic Surgeons
Cardiac Surgery
Collaborative Quality Initiative
Etc.
9
PGIP Participants (June 2008)
•
•
•
Marquette County: Upper Peninsula Health Plan (176)
35 groups
6,471 physicians
1,700,000 members
Ontonagon
Genesee County: Genesys Integrated
Group Physicians(87), Hurley PHO (116),
McLaren Medical Management (95)
Baraga
Luce
Marquette
Gogebic
Alger
Iron
Dickinson
Schoolcraft
Chippewa
Oakland County: Medical Network One (303),
Oakland Physician Network Services (144),
Oakland Southfield Physicians (204), Oncology
Physician Resource (64), Quality Partners of
MI (34), St. John Medical Group (223), United
Physicians (560)
Mackinac
Delta
Saginaw County: Primary
Healthcare Partners (57)
Emmet
Cheboygan
St. Clair County: Mercy~ Physician
Community PHO (38), Physician
Healthcare Network (26)
Charlevoix
Kent County: Advantage Health
Physicians (146), Michigan Medical, PC
(MMPC) (90), Regional Delivery
Network of West MI (136), West
Michigan Physicians Network (227)
Muskegon County:
Hackley PHO (79)
Presque
Isle
Alpena
Otsego
Antrim
Leelanau
Grand Kalkaska
Oscoda
Benzie Traverse
Crawford
Manistee
Wexford
Macomb County: DMC
Primary Care Physicians
(115), St. John
HealthPartners (417)
Alcona
Missaukee
Ogemaw
Roscommon
Iosco
Arenac
Mason Lake
Ottawa County: Principal
Health PHO (35)
Osceola Clare
Wayne County: Henry Ford
Medical Group (328),
Olympia Medical Services
(127), UOP, LLC (252)
Gladwin
Huron
Mecosta
Oceana
Isabella
Bay
Tuscola
Montcalm
Ingham County: Consortium of
Independent Physician Associations
(1,230), MSU Health Team (104),
Sparrow Family Medical Services (45)
Gratiot
Genesee Lapeer
Ottawa
10
Kent
Allegan
Calhoun County: Integrated Health Partners (69)
Kalamazoo County: Bronson
Medical Group (50) and ProMed
Healthcare (83)
Sanilac
Saginaw
Van Buren
Berrien
Cass
Ionia
Barry
Clinton
Eaton
Shiawassee
Macomb
Oakland
Ingham
Livingston
Calhoun Jackson
Washtenaw
Kalamazoo
St. Joseph
Branch
Hillsdale
St. Clair
Wayne
Monroe
Washtenaw County: Huron
Valley Physicians
Association (245), Integrated
Health Associates (109), UM Health System Faculty
Group Practice (387)
Jackson County: Jackson Physician
Alliance (70)
Lenawee
10
ValuePartnerships: Leveraging Provider
Relationships and Market Share to
transform healthcare delivery.
Next-Generation PPO
Current
State
Partnering for Value
• Stronger role for primary care
(medical home, not gatekeeper)
• Strong link between performance
and payment
Foundation for Future
ShortTerm
Value
•
•
Preparations
•
Incremental
Savings and
Improvement
•
11
Build effective physician
organizations.
Care commitment to a
defined population
Facilitated practice
improvement and
technology
dissemination.
Substantial improvement
in healthcare delivery
Programs to Improve Hospital Care:
MHA Keystone: Hospital-Associated Infection
(HAI)
The Challenge:
• 5-10% of hospital inpatients develop infections each year,
resulting in 90,000 deaths nationally
• $5 billion to $6 billion in national health care costs
The Response:
• Launched in 2007 to eliminate Hospital Associated Infections
• Hand hygiene compliance nearly 80% (U.S. average is 40%)
• Eliminating nonessential catheters
• 112 participating hospitals in MHA Keystone: HAI
12
Keystone Results in Michigan
• Lives Saved – 1,729*
• Patient Days Saved – in excess of 127,000*
• Dollars Saved – 0ver $246 Million*
• Culture of Safety improved 28%
• Teamwork improved 15%
* Based on the Johns Hopkins Opportunity Calculator
13
Improving Cardiac Interventions – Participating Centers
– 2009
14
Percent
Comparison of Outcomes for 2002-2008*
20
2002
2008
15
40%
10
5
22%
1.5%
18%
25%
26%
0
Death
Kidney
Failure
15
Transfusion
Vascular
Complications
All CABG
Revasc
Improving Performance to the Population:
Evidence Based Care Measures
2008 Measures (scored in 2008)
• Diabetes
– Comprehensive Diabetes Care - HbA1c Testing
– Comprehensive Diabetes Care - LDL-C Screening
– Comprehensive Diabetes Care - Monitoring Nephropathy
– Lipid Lowering Drug Rate
– Statin Therapy for Persons with Diabetes
– ACE/ARB Use with Comorbidity CHF
– ACE/ARB Use with Comorbidity Nephropathy
– ACE/ARB Use with Comorbidity Hypertension
• Asthma
– Use of Appropriate Medications for People with Asthma –
Combined
• Congestive Heart Failure (CHF)
– LDL-C Screening
– Beta Blocker Prescription over Last 12 Months
– Rate of ACE/ARB
• Coronary Artery Disease (CAD)
– Beta Blocker Treatment After a Heart Attack
– Cholesterol Management for Patients with Cardiovascular
Conditions - Screening
– Lipid Lowering Drug Rate
– Statin Use
• Additional Measures
– Appropriate Treatment for Children with an Upper Respiratory
Infection
– Avoidance of Antibiotic Treatment in Adults with Acute
Bronchitis
New Measures for 2008 (scored in 2009)
•Adult Prevention
– Breast Cancer Screening
– Cervical Cancer Screening
•Child/Adolescent Prevention/Treatment
– Adolescent Well Care Visit
– Adolescent Immunization Status – Combo 2
– Childhood Immunization Status – Combo 3
– Well Child Visits in First 15 Months of Life
– Well Child Visits in 3, 4, 5, 6 Years of Life
•Chronic Obstructive Pulmonary Disease (COPD)
– Use of Spirometry in Assessment and Diagnosis
•Congestive Heart Failure (CHF)
– ACE/ARB Continuation/Persistence
•Coronary Artery Disease (CAD)
– Persistence of Beta Blocker Treatment After AMI
•Low Back Pain
– Imaging Studies for Low Back Pain
16
16
EBCR Performance Trend
PGIP Improvement in Evidence Based Care Measures:
PGIP Overall EBCR Score by Measurement Period
80%
ABC
Benchmark
78%
76%
Overall EBCR Score
75%
75%
72%
71%
70%
69%
68%
65%
60%
2006
2Q06-1Q07
3Q06-2Q07
4Q06-3Q07
Measurement Period
17
2007
2Q07-1Q08
U
of
va M
nt
a
H ge
ac
kl
ey
W
IH
es
A
tM
M
I/ S
pe SU
ct
ru
O m
ly
m
pi
a
R
D
N
H
FH
Pr S
om
ed
H
U
ni
C V
te ov PA
d
Ph ena
y s nt
ic
ia
Sp ns
ar
ro
w
U
O
Pr
P
O
in
PN
ci
pa
lH S S
ea JM
l th G
PH
O
Ja SJ
ck H
so P
n
Br PA
on
so
n
IH
M
cL P
ar
en
M
er
cy
O
C
ak
IP
la
nd U A
So PH
ut P
hf
ie
ld
D
M
C
M
N
O
H
ur
G ley
en
es
ys
PH
N
PG
IP
Ad
Overall EBCR Score (Original 18 Measures)
1Q 2008 EBCR Performance
1Q 2008 Overall EBCR Score by Physician Organization
85%
83%
83%
81%
80%
80%
75%
79%79%79%
79%
78%
77%77%
77%77%77%77%76%
76%76%
76%76%75%
75%75%75%
74%74%74%
73%
73%73%73%
70%
18
76%
70%
65%
60%
Increasing Generic Use
PGIP Generic Dispensing Rate Improvement
64%
65%
64%
61%
59%
60%
57%
60%
56%
59%
55%
Generic Dispensing Rate
55%
56%
53%
55%
52%
49%
50%
51%
54%
54%
52%
50%
51%
48%
49%
49%
50%
PGIP
Control
45%
40%
35%
30%
3Q05
4Q05
1Q06
2Q06
3Q06
4Q06
1Q07
Quarter
19
2Q07
3Q07
4Q07
1Q08
2Q08
PMPM by Year
Initial PMPM
Difference=
$120.00 $4.84
$100.00
Overall PMPM PGIP vs. Control by Year
$96.20
$95.40
Final
Difference=$21.08
Savings=$16.24 PMPM
$97.81
$85.89
$90.56
$80.00
PMPM
$80.43
$77.77
$76.73
Control
PGIP
$60.00
$40.00
$20.00
$0.00
202005
2006
2007
2008
Improving Primary Care Performance
• Performance assessment is based on attributed
population rates.
– PC-MH practice characteristics, based on national
criteria
– Performance on Quality metrics – “Evidence-Based Care
Report”
– Resource management
•
•
•
•
Generic dispensing rate
High tech imaging
Low tech imaging
Rate of use of ER for non-emergent care
21
Building the Primary Care Foundation:
Patient Centered Medical Home
PGIP Phys Org B
PC-MH
PGIP Phys Org A
PCP
PC-MH
PCP
PCP
PCP
PCP
PCP
PCP
PC-MH
Nominee
PCP
PCP
PCP
PCP
PCP
PCP
PCP
PC-MH
Nominee
PCP
PCP
PCP
PCP
22
PCP
PCP
PCP
PCP
PCP
PCP
PCP
PC-MH
PCP
PCP
PGIP Phys Org C
PCP
PC-MH
Nominee
PCP
PCP
PCP
“Control
Group”
PCP
PCP
PCP
PCP
PCP
PCP
PCP
PCP
PCP
Summary
• Michigan has unfavorable health status and medical costs
compared to regional and national benchmarks.
• BCBSM is working to make Michigan a more competitive state
to attract business and job growth, while improving medical
care.
• Health Plan-based Wellness and Care Management programs
are cost-effective and act as a safety net for failure of the
primary clinical process, but they do not change healthcare
delivery and do not significantly affect health benefit costs.
• Population-based collaborative programs improve key clinical
processes and achieve substantial savings.
• PCP’s are actively transforming their practices by implementing
the Patient-Centered Medical Home model, creating a lower
cost model of care.
23