Innovative Health Care Policies: Using ACO Principles and Financial Incentives
to Improve Health Outcomes
Web SeminarWeb Seminar
January 29, 2013January 29, 2013
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Today’s HostToday’s Host
Judi ConsalvoJudi Consalvo
Program Analyst at AHRQ Center Program Analyst at AHRQ Center for Outcomes and Evidencefor Outcomes and Evidence
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What Is the Health CareWhat Is the Health CareInnovations Exchange? Innovations Exchange?
Publicly accessible, searchable database of health policy Publicly accessible, searchable database of health policy and service delivery innovationsand service delivery innovations
Searchable QualityToolsSearchable QualityTools Successes and attemptsSuccesses and attempts Innovators’ stories and lessons learnedInnovators’ stories and lessons learned Expert commentariesExpert commentaries Learning and networking opportunitiesLearning and networking opportunities New content posted to the Web site every two weeks New content posted to the Web site every two weeks
Sign up at Sign up at http://http://www.innovations.ahrq.govwww.innovations.ahrq.gov under “Stay under “Stay Connected”Connected”
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Innovations Exchange Innovations Exchange Web Event SeriesWeb Event Series
How to find archived materialsHow to find archived materialsGo to Go to http://www.innovations.ahrq.gov to the Events to the Events
& Podcasts tab. A transcript of this event along & Podcasts tab. A transcript of this event along with the slides will be available within two weeks with the slides will be available within two weeks
Next EventsNext EventsJoin our Tweetchat – February 27, 2013Join our Tweetchat – February 27, 2013Chats on Change: Supporting Priority PopulationsChats on Change: Supporting Priority Populations
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Today’s Event ModeratorToday’s Event Moderator
Gerry Fairbrother, PhDGerry Fairbrother, PhD
Senior Scholar at AcademyHealthSenior Scholar at AcademyHealth
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Identifying Health Care Identifying Health Care Policy InnovationsPolicy Innovations
AcademyHealth is pleased to work with AcademyHealth is pleased to work with Westat and AHRQ on identifying health Westat and AHRQ on identifying health care policy innovationscare policy innovations
Major policy innovations in 2013: Major policy innovations in 2013: Accountable Care Organizations, Accountable Care Organizations, payment reforms, quality improvement payment reforms, quality improvement initiativesinitiatives
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Innovations Presented Innovations Presented TodayToday
The Blue Cross Blue Shield of Michigan The Blue Cross Blue Shield of Michigan and Montefiore Medical Centerand Montefiore Medical Center
A payer driven quality improvement A payer driven quality improvement initiative and an ACOinitiative and an ACO
Both timely and cutting edge innovationsBoth timely and cutting edge innovations
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David Share, MD, MPHDavid Share, MD, MPH
Blue Cross Blue Shield of Blue Cross Blue Shield of MichiganMichigan
Lauren Henrikson-Lauren Henrikson-Warzynski, MPAWarzynski, MPA
Health Care AnalystHealth Care AnalystSenior Vice President of Senior Vice President of
Value PartnershipsValue Partnerships11
Improving Healthcare Through Improving Healthcare Through Collaborative PartnershipsCollaborative Partnerships
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What are Collaborative What are Collaborative Quality Initiatives?Quality Initiatives?
Structure of Collaborative Quality Initiatives Structure of Collaborative Quality Initiatives (CQIs): developed and administered by (CQIs): developed and administered by Michigan physician and hospital partners, Michigan physician and hospital partners, funded by BCBSM and its HMO, Blue Care funded by BCBSM and its HMO, Blue Care NetworkNetwork
Support continuous quality improvement and Support continuous quality improvement and the development of best practices the development of best practices
Leverage inter-institutional data registriesLeverage inter-institutional data registries Why? Reduce avoidable adverse events, Why? Reduce avoidable adverse events,
provide incentives and track performanceprovide incentives and track performance
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Why Do We Need CQIs?Why Do We Need CQIs?
Quality of health care remains suboptimal, Quality of health care remains suboptimal, with wide variations in performance across with wide variations in performance across institutions and avoidable adverse events institutions and avoidable adverse events
Suboptimal quality affects patients’ health; Suboptimal quality affects patients’ health; drives up costs drives up costs
Regional collaborations can provide incentives Regional collaborations can provide incentives and infrastructure to systematically track and and infrastructure to systematically track and improve performanceimprove performance
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Overall Goals Overall Goals of the CQI Programof the CQI Program
Examine the link between care processes and Examine the link between care processes and outcomes in complex, highly technical areas of careoutcomes in complex, highly technical areas of care
Measure the quality of care within and across systems Measure the quality of care within and across systems
Create a feedback loop for continuous quality Create a feedback loop for continuous quality improvement with participating institutions improvement with participating institutions
Identify “clinical champions” at each participating Identify “clinical champions” at each participating hospital hospital
Implement fast-track quality improvement initiatives Implement fast-track quality improvement initiatives targeted at specific, high-leverage procedurestargeted at specific, high-leverage procedures
Continue to demonstrate to consumers and Continue to demonstrate to consumers and purchasers of care that CQIs positively impact systems purchasers of care that CQIs positively impact systems of careof care
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The BeginningThe Beginning
Collaborative study on the variation in angioplasty Collaborative study on the variation in angioplasty procedures and treatment (1997)procedures and treatment (1997)
Resulted in decreases in mortality, kidney failure, Resulted in decreases in mortality, kidney failure, emergency bypass surgeries and other emergency bypass surgeries and other complications complications
Fostered development of a culture in which Fostered development of a culture in which stakeholders pool efforts and best thinking to stakeholders pool efforts and best thinking to optimize practices, systems and outcomes of careoptimize practices, systems and outcomes of care
Collaboration was necessary for real changeCollaboration was necessary for real change
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Current CQI ProgramsCurrent CQI Programs
BCBSM/BCN Collaborative Quality Initiatives
Hospital-based 12
New Hospital-based (2013) 2
Hospital/Provider-based 1
Professional 5
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CQI Program FrameworkCQI Program Framework
• Offer neutral ground for collaboration
• Program funding and incentive payment design
• Clinical leadership• Analytic and quality
improvement support
CQI
Continuous Quality
Improvement
• Contribute to the all-payer registry
• Share and learn from best practices
Consortium
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CQI Financial SupportCQI Financial Support
Hospital CQIs: Hospital CQIs: Data collection for BCBSM/BCN, Medicare and Medicaid, and uninsured Data collection for BCBSM/BCN, Medicare and Medicaid, and uninsured
members (estimated 80% of data collection costs)members (estimated 80% of data collection costs) The CQI Coordinating CenterThe CQI Coordinating Center
Professional CQIs:Professional CQIs: Registry-based CQIs: Data collection for BCBSM/BCN, Medicare and Registry-based CQIs: Data collection for BCBSM/BCN, Medicare and
Medicaid, and uninsured members (estimated 80% of data collection Medicaid, and uninsured members (estimated 80% of data collection costs)costs)
Non-registry-based CQIs: a portion of staff resources for CQI-related Non-registry-based CQIs: a portion of staff resources for CQI-related processes processes
The CQI Coordinating CenterThe CQI Coordinating Center
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CQI Incentive PaymentCQI Incentive Payment
Hospital CQIs: Hospital CQIs: Active participation and improved outcomes are rewarded Active participation and improved outcomes are rewarded
through BCBSM’s incentive programthrough BCBSM’s incentive program Engaged physicians for select CQIs may receive a Engaged physicians for select CQIs may receive a
recognition payment through service codes beginning recognition payment through service codes beginning February 2013February 2013
Professional CQIs:Professional CQIs: Active participation and improved outcomes as reflected in Active participation and improved outcomes as reflected in
the metrics through the Physician Group Incentive Program the metrics through the Physician Group Incentive Program
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CQI ParticipationCQI Participation
High levels of participation throughout MichiganHigh levels of participation throughout Michigan 95% of eligible hospitals participate in at least 95% of eligible hospitals participate in at least
one Hospital CQIone Hospital CQI 73% of hospitals participate in all of the 73% of hospitals participate in all of the
Hospital CQI programs for which they are Hospital CQI programs for which they are eligibleeligible
Over 329 physician practices participate in at Over 329 physician practices participate in at least one Professional CQIleast one Professional CQI
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Angioplasty CQI: OutcomesAngioplasty CQI: Outcomes
Between 2002 and Q3 2011, death has declined by 20%, contrast induced nephropathy Between 2002 and Q3 2011, death has declined by 20%, contrast induced nephropathy (CIN) by 38%, transfusions by 38%, vascular complications by 44%, emergency coronary (CIN) by 38%, transfusions by 38%, vascular complications by 44%, emergency coronary artery bypass grafting (CABG) by 92% and revascularizations by 17%artery bypass grafting (CABG) by 92% and revascularizations by 17%
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Hospital CQI SavingsHospital CQI Savings Over 2-3 years, 4 participating programs Over 2-3 years, 4 participating programs
produced $232.8 million in health care cost produced $232.8 million in health care cost savings savings
Complications and mortality rates lowered for Complications and mortality rates lowered for thousands of patientsthousands of patients Michigan Surgical Quality Collaborative (general surgery)Michigan Surgical Quality Collaborative (general surgery)
2009-2010: $ 85.9 million statewide savings; $49.2 million BCBSM savings2009-2010: $ 85.9 million statewide savings; $49.2 million BCBSM savings
Michigan Society of Thoracic and Cardiovascular Surgeons (cardiac surgery)Michigan Society of Thoracic and Cardiovascular Surgeons (cardiac surgery)2009-2010: $30.3 million statewide savings; $2.4 million BCBSM savings2009-2010: $30.3 million statewide savings; $2.4 million BCBSM savings
Michigan Cardiovascular Consortium - Percutaneous Coronary Intervention Michigan Cardiovascular Consortium - Percutaneous Coronary Intervention (angioplasty)(angioplasty)2008-2010: $102 million statewide savings; $13.8 million BCBSM savings2008-2010: $102 million statewide savings; $13.8 million BCBSM savings
Michigan Bariatric Surgery Collaborative (bariatric surgery)Michigan Bariatric Surgery Collaborative (bariatric surgery)2008-2010 : $14.6 million statewide savings; $4.7 million BCBSM savings2008-2010 : $14.6 million statewide savings; $4.7 million BCBSM savings
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Award Award Winning PartnershipsWinning Partnerships
Best of Blue Clinical Distinction AwardBest of Blue Clinical Distinction Award Michigan Surgical Quality Collaborative (2011)Michigan Surgical Quality Collaborative (2011) Michigan Bariatric Surgery Collaborative (2011)Michigan Bariatric Surgery Collaborative (2011) Quality Oncology Practice Initiative (2011)Quality Oncology Practice Initiative (2011) BMC2 – Percutaneous Coronary Intervention (2012)BMC2 – Percutaneous Coronary Intervention (2012) PGIP – “Fee for Value” (2012)PGIP – “Fee for Value” (2012)
Michigan Cancer Consortium Spirit of Collaboration Michigan Cancer Consortium Spirit of Collaboration Award (2011) Award (2011)
Quality Oncology Practice InitiativeQuality Oncology Practice Initiative Michigan Breast Oncology Quality InitiativeMichigan Breast Oncology Quality Initiative Michigan Oncology Clinical Treatment Pathways Michigan Oncology Clinical Treatment Pathways
Cancer Innovator Award (2011) Cancer Innovator Award (2011)
eValue8 Health Plan Innovation Award (2008) eValue8 Health Plan Innovation Award (2008) 24
CQI Model: Why It WorksCQI Model: Why It Works
Empowering the provider community to use comparative Empowering the provider community to use comparative effectiveness research in a collaborative contexteffectiveness research in a collaborative context
Measurement to inform is more powerful than Measurement to inform is more powerful than measurement to judge; BCBSM does not see individual measurement to judge; BCBSM does not see individual hospital datahospital data
Intrinsic motivation of professionals is harnessed when the Intrinsic motivation of professionals is harnessed when the work is owned and conducted by themwork is owned and conducted by them
Incentives focused on:Incentives focused on:
– Participation to help pay for the cost of data collection; and Participation to help pay for the cost of data collection; and
– Performance, to reward active and results-oriented participation Performance, to reward active and results-oriented participation catalyzes engagement and improved results.catalyzes engagement and improved results.
Focus on long-term transformation of care processes Focus on long-term transformation of care processes improves systems of careimproves systems of care
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Key TakeawaysKey Takeaways
CQIs support continuous quality improvement and development of best practices for areas of care CQIs support continuous quality improvement and development of best practices for areas of care that are highly technical, rapidly-evolving, and associated with scientific uncertainty. that are highly technical, rapidly-evolving, and associated with scientific uncertainty.
Collaborating across institutions accelerates improvement; more can be learned from variation in Collaborating across institutions accelerates improvement; more can be learned from variation in care processes and outcomes across groups than within groups.care processes and outcomes across groups than within groups.
CQIs target common clinical conditions and procedures associated with high costs per episode. CQIs target common clinical conditions and procedures associated with high costs per episode.
CQIs gather data on patient risk factors, processes and outcomes of care. Use data to generate CQIs gather data on patient risk factors, processes and outcomes of care. Use data to generate risk adjusted comparative performance analyses and guide quality improvement interventions. risk adjusted comparative performance analyses and guide quality improvement interventions.
CQIs help to further BCBSM's social mission of cultivating a healthier future for all Michigan CQIs help to further BCBSM's social mission of cultivating a healthier future for all Michigan residents. residents.
Patients, regardless of payer, benefit from improved care processes developed through an all-Patients, regardless of payer, benefit from improved care processes developed through an all-patient approach to practice transformation. patient approach to practice transformation.
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The Future of CQIsThe Future of CQIs
Ongoing CQI and Overall Program Evaluation Ongoing CQI and Overall Program Evaluation including NIH-funded ROI analysisincluding NIH-funded ROI analysis
Michigan Spine Surgery Improvement Collaborative Michigan Spine Surgery Improvement Collaborative Aims: To improve the quality of care of spinal surgery by enhancing Aims: To improve the quality of care of spinal surgery by enhancing patient-reported outcomes following spine surgery; reduce surgical patient-reported outcomes following spine surgery; reduce surgical complications; reduce average costs of surgeries and episodes of care; complications; reduce average costs of surgeries and episodes of care; and reduce the rate of repeat spine surgeries.and reduce the rate of repeat spine surgeries.
Michigan Value Collaborative Michigan Value Collaborative Aims: To profile approximately 20 common inpatient conditions and Aims: To profile approximately 20 common inpatient conditions and procedures; to partner with existing CQIs to present findings and lead procedures; to partner with existing CQIs to present findings and lead discussions; and collaborate in designing and evaluating improvement discussions; and collaborate in designing and evaluating improvement interventions.interventions.
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Montefiore Medical CenterMontefiore Medical CenterStephen Rosenthal, MBA, MSStephen Rosenthal, MBA, MS
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President and Chief Operating Officer at thePresident and Chief Operating Officer at theMontefiore Care Management Organization (CMO)Montefiore Care Management Organization (CMO)
Montefiore: More than a HospitalMontefiore: More than a Hospital
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Where We AreWhere We AreHigh-Cost, High-Volume EnvironmentHigh-Cost, High-Volume Environment
High Volume:High Volume: Over 90,000 admissions annuallyOver 90,000 admissions annually 3.5 million ambulatory care visits annually3.5 million ambulatory care visits annually 500,000 home care agency visits annually500,000 home care agency visits annually
Bronx, New York:Bronx, New York: 1.4 million people, 31% poor (vs. 21% across New 1.4 million people, 31% poor (vs. 21% across New
York) and 90% Hispanic and/or BlackYork) and 90% Hispanic and/or Black Higher prevalence of diabetes, obesity, asthma, Higher prevalence of diabetes, obesity, asthma,
other chronic conditions than New York City other chronic conditions than New York City 20% higher per capita medical expense than US20% higher per capita medical expense than US 8% of population 8% of population 50% medical expense 50% medical expense
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Our StructureOur Structure
Formed in 1995Formed in 1995 MD/ Hospital PartnershipMD/ Hospital Partnership Contracts with managed Contracts with managed
care organizations to care organizations to accept and manage riskaccept and manage risk
Over 2,400 physician Over 2,400 physician membersmembers
– Over 500 PCPsOver 500 PCPs
– Over 1,900 SpecialistsOver 1,900 Specialists
Established in 1996Established in 1996 Wholly-owned subsidiary of Wholly-owned subsidiary of
Montefiore Medical CenterMontefiore Medical Center Performs Performs care management care management
delegated by health plans, delegated by health plans, other administrative other administrative functions, (e.g. claims functions, (e.g. claims payment, credentialing)payment, credentialing)
Licensed Utilization Review Licensed Utilization Review agent and certified claims agent and certified claims adjustorsadjustors
Montefiore IPAIntegrated Provider Association
Montefiore IPAIntegrated Provider Association
CMOCare Management Company
CMOCare Management Company
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MIPA and CMO MIPA and CMO Cont.Cont.
Premium $Premium $
Insurance CompanyInsurance Company
CMOCMO MIPAMIPA
HospitalHospital
Savings
Specialty Care
Specialty Care
Primary Care
Primary Care
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How We Got Started How We Got Started Catalysts for InnovationCatalysts for Innovation
Reality of population Montefiore serves: low Reality of population Montefiore serves: low income, with chronic illnessesincome, with chronic illnesses
Early advent of managed care and the need for Early advent of managed care and the need for Montefiore to manage the premiumMontefiore to manage the premium
Significant competition among insurance Significant competition among insurance companies companies insurers saw partnering with us insurers saw partnering with us as opportunity to grow market shareas opportunity to grow market shareAlso substantial competition among provider groupsAlso substantial competition among provider groups
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How We Got StartedHow We Got StartedEarly QuestionsEarly Questions
Why Fill the Care Management Gap:Why Fill the Care Management Gap: Dominant presence in the BronxDominant presence in the Bronx Developed diverse set of primary care practices through Developed diverse set of primary care practices through
which to serve beneficiaries which to serve beneficiaries Improved relationships with providers in the communityImproved relationships with providers in the community
Decision Points:Decision Points: Determining the structure - combination of legal Determining the structure - combination of legal
parameters and financial considerationsparameters and financial considerations Seeking risk arrangements with payers vs. becoming a Seeking risk arrangements with payers vs. becoming a
payerpayer Focusing on particular care management and network Focusing on particular care management and network
support functions support functions Which payers to target initially and longer termWhich payers to target initially and longer term
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ImplementationImplementation
Worked with a few key partners:Worked with a few key partners: Collaborated with healthcare leaders to brainstormCollaborated with healthcare leaders to brainstorm Participated in National IPA coalition to learn about Participated in National IPA coalition to learn about
practices used across the countrypractices used across the country
Developed agreements with payers:Developed agreements with payers: First needed to understand their populationsFirst needed to understand their populations Getting the correct payment was criticalGetting the correct payment was critical Used a consistent model (full risk) Used a consistent model (full risk)
Getting up and running:Getting up and running: Cultivated a dedicated workforceCultivated a dedicated workforce Focused on transactional aspects of the business e.g. Focused on transactional aspects of the business e.g.
timely claims paymenttimely claims payment Understood the benefit packages and what employers Understood the benefit packages and what employers
expected of insurance companiesexpected of insurance companies At start, systems limitations were challengingAt start, systems limitations were challenging
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Our Current PortfolioOur Current Portfolio
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Initiative 2012 Population
2012 Est. Revenue
2013 Population
2013 Est. Revenue
Risk Contracts 140,000 $850 m 185,000 $1,085 m
Shared Risk 78,000 $490 m 80,000 $685 m
Medicaid Health Home (Care Coordination)
10,000 $10 m 10,000 $18 m
TOTAL 228,000 $1,350 m 270,000 $1,788 m
Strategic ApproachStrategic ApproachPopulation StratificationPopulation Stratification
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Self-IDData
Mining
Sentinel Events, e.g. Post
Discharge
MDReferrals
POPULATION
APPLICATION OF SCREENING LOGIC
WELL &
WORRIEDWELL
FUNCTIONALCHRONICALLY
ILL
FRAIL ILL/HIGH UTILIZERS
STRATIFICATION
INTERVENTION
INTENSITY
INTERVENTIONS ARE TARGETED TO MEMBERS HEALTH INFORMATION ACCESSED BY CAREGIVERS, AS NEEDED
* Intensive/complex case management* Palliative care* Transitional care management
MEMBERS ACCESS INFORMATION, AS NEEDED
* My Montefiore* General Health Information* PHR
MEMBERS ACCESS INFORMATION, AS NEEDEDHEALTH EDUCATION & INTERVENTIONS ARE TARGETED TO MEMBERS
* Self-management/empowerment tools* Customized assessments
WELL & WORRIED WELL
FUNCTIONAL CHRONICALLY ILL
FRAIL ILL/HIGH UTILIZERS
LOW
HIGH
Care Guidance ModelCare Guidance Model
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OutcomesOutcomesPost-Discharge Call Program Post-Discharge Call Program
Readmission Rate Decreased 33% Readmission Rate Decreased 33%
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30-Day Readmission Rates
24.9%
21.5%
14.1%
0%
5%
10%
15%
20%
25%
30%
2008 Baseline (pre-program)
(n= 2,809)
2009-2010 High-Risk
Not Reached(n= 1,258)
2009-2010 High-Risk
Reached/ Assessed(n= 2,187)
At-risk patients defined as: age >69; having had a readmission in past 60 days; or having had home care services prior to admission
OutcomesOutcomesEffective Management of Diabetes Effective Management of Diabetes
12% Drop in Total Costs12% Drop in Total Costs
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Source: CMO Paid Claims; Author: H. Shao
Notes: Rx costs not available. Projected Costs Estimated using healthcare inflation trend of 16%
Key TakeawaysKey TakeawaysCare CoordinationCare Coordination
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Individual level:Individual level: Focus assessments on medical and psychosocial issuesFocus assessments on medical and psychosocial issues Expand capability to work with participants face to faceExpand capability to work with participants face to face Incorporate tools to support individual behavior changeIncorporate tools to support individual behavior change
Provider level:Provider level: Improve access and availabilityImprove access and availability Expand PCMH infrastructureExpand PCMH infrastructure Incorporate behavioral health expertise into care managementIncorporate behavioral health expertise into care management
System level:System level: Support organizational behaviors that reduce preventable utilizationSupport organizational behaviors that reduce preventable utilization Partner to identify vulnerable patients and create comprehensive care plansPartner to identify vulnerable patients and create comprehensive care plans Develop IT infrastructure to support cross-organizational communication and data exchangeDevelop IT infrastructure to support cross-organizational communication and data exchange
Key TakeawaysKey TakeawaysPromoting an Accountable Delivery SystemPromoting an Accountable Delivery System
Organizational governance, structure, alignment, and Organizational governance, structure, alignment, and data are the foundationdata are the foundation
Must define and understand the populationMust define and understand the population <20% of the population determine the costs 100% <20% of the population determine the costs 100%
determine the quality of caredetermine the quality of care Sustainable cost reduction, improve performance and Sustainable cost reduction, improve performance and
patient-centered care only with delivery system patient-centered care only with delivery system transformationtransformation
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Key TakeawaysKey TakeawaysSetting the Stage for GrowthSetting the Stage for Growth
Use empirical evidence to support the spread Use empirical evidence to support the spread of your best practiceof your best practice
Develop or engage in forums for sharing Develop or engage in forums for sharing information (like AHRQ’s Innovation information (like AHRQ’s Innovation Exchange) to engage new champions Exchange) to engage new champions
Leverage technology to advance your Leverage technology to advance your success; need technology to move information success; need technology to move information to the right people at the right time and to to the right people at the right time and to enable staff to practice at the top of their enable staff to practice at the top of their licenselicense
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What’s Next?What’s Next?
New targeted interventions for select groups New targeted interventions for select groups Additional interventions for skilled nursing Additional interventions for skilled nursing
facility (SNF) residentsfacility (SNF) residents Expand linkage with community-based Expand linkage with community-based
providersproviders Expand strategies for beneficiary engagementExpand strategies for beneficiary engagement Focus on patient satisfaction (33 ACO quality Focus on patient satisfaction (33 ACO quality
measures)measures) Expand current programsExpand current programs
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RespondentRespondent
Xavier Sevilla, MD, MBA, FAAP Xavier Sevilla, MD, MBA, FAAP
Vice President for Clinical Quality
Catholic Health Initiatives, Denver, Colorado
Quality Health Policy Quality Health Policy BackgroundBackground
2000 To Err is Human: Call to improve the delivery system as a whole2000 To Err is Human: Call to improve the delivery system as a whole 2001 Crossing the Chasm: 6 Quality Dimensions, 10 Rules for 2001 Crossing the Chasm: 6 Quality Dimensions, 10 Rules for
Redesign of Health CareRedesign of Health Care 2007 Joint Principles of the Patient Centered Medical Home2007 Joint Principles of the Patient Centered Medical Home 2007 IHI Triple Aim 2007 IHI Triple Aim
Quality Health Policy Quality Health Policy BackgroundBackground
New approach to measuring quality: National Quality Strategy April 2011 New approach to measuring quality: National Quality Strategy April 2011 Better careBetter care Healthy communitiesHealthy communities More affordable careMore affordable care
ACO Medicare Shared Savings Program 2012ACO Medicare Shared Savings Program 2012
Current Landscape in Current Landscape in Health Care Policy/ QualityHealth Care Policy/ Quality
Using data to build a culture of quality: Slow improvement in quality (2.5% Using data to build a culture of quality: Slow improvement in quality (2.5% per year)per year)
Delivery system transformationDelivery system transformation Aligning payment policies with qualityAligning payment policies with quality Bending the cost curve: $2.7 trillion, $1 out of every $6 in the economyBending the cost curve: $2.7 trillion, $1 out of every $6 in the economy
Using Data to Build a Using Data to Build a Culture of QualityCulture of Quality
Pediatrix Medical GroupPediatrix Medical Group
Clinical Data WarehouseClinical Data Warehouse Automated data extraction from EHRAutomated data extraction from EHR Accessible and easy to use at the bedsideAccessible and easy to use at the bedside Extensive data validationExtensive data validation
Decreased clinical variation Decreased clinical variation Data down to individual clinicianData down to individual clinician Change culture to ongoing continuous quality improvementChange culture to ongoing continuous quality improvement
Delivery System Delivery System Transformation Transformation
HealthPartners in MinnesotaHealthPartners in Minnesota““Prepared practice teams interacting with informed, activated Prepared practice teams interacting with informed, activated patients through continuous healing relationships supported by patients through continuous healing relationships supported by ongoing availability of health information”ongoing availability of health information”Care Model Process (Delivery System)Care Model Process (Delivery System)
Team based careTeam based care Primary care based systemPrimary care based system Reliable, timely and actionable dataReliable, timely and actionable data Change of clinician’s cultureChange of clinician’s culture
Aligning Payment Policies Aligning Payment Policies with Quality Improvementwith Quality Improvement
Zero sum game between payers / providers: Zero sum game between payers / providers: wrong kind of competition, shifting costs, wrong kind of competition, shifting costs, increase bargaining power, restrict choiceincrease bargaining power, restrict choice
Competition should be on creating valueCompetition should be on creating value Shift from pay for performance to pay for Shift from pay for performance to pay for
valuevalue
Status of Pay for Status of Pay for PerformancePerformance
Quality and Outcomes Framework Britain’s Quality and Outcomes Framework Britain’s National Health Service (2004)National Health Service (2004)““Overall only a modest improvement in quality”Overall only a modest improvement in quality”““Pay for performance had no discernible effects Pay for performance had no discernible effects on processes of care or on hypertension related on processes of care or on hypertension related clinical outcomes” clinical outcomes”
– BMJ 2011;342:d108BMJ 2011;342:d108
Alternative Quality ContractAlternative Quality ContractBCBS of MassachusettsBCBS of Massachusetts
Unique Contract Model: Accountability for quality and Unique Contract Model: Accountability for quality and utilization, long term - 5 yearsutilization, long term - 5 years
Controls Cost Growth: Global payment, payment to Controls Cost Growth: Global payment, payment to adjust for inflation, incentive to eliminate overuseadjust for inflation, incentive to eliminate overuse
Improved Quality and Outcomes: Bonus payments up to Improved Quality and Outcomes: Bonus payments up to 10% of the total contract, used widely accepted quality 10% of the total contract, used widely accepted quality measures, outcome had more weight than process, measures, outcome had more weight than process, frequent performance reports frequent performance reports
Bending the Cost CurveBending the Cost Curve
Bellin Health (Wisconsin): decreased health Bellin Health (Wisconsin): decreased health cost, health care costs below the national cost, health care costs below the national average for external employersaverage for external employers
Health knowledge of the population: health risk Health knowledge of the population: health risk assessments for all patientsassessments for all patients
Care management for at risk patientsCare management for at risk patients Integrated system of care coordination: nurse Integrated system of care coordination: nurse
call line entry point, primary carecall line entry point, primary care Created a culture of health Created a culture of health
ConclusionsConclusions
Reform of the health care system is not only Reform of the health care system is not only possible, but is flourishing in a number possible, but is flourishing in a number organizations such as Montefiore and BCBS organizations such as Montefiore and BCBS MichiganMichigan
Visionary leaders are not waiting to see what the Visionary leaders are not waiting to see what the new healthcare environment will look like but are new healthcare environment will look like but are innovating to improve their organizations today and innovating to improve their organizations today and position them for the futureposition them for the future
The Future of Health Care The Future of Health Care Policy InnovationsPolicy Innovations
Partnerships and collaboration Partnerships and collaboration
The new roles for patientsThe new roles for patients
Sick care versus wellness Sick care versus wellness
Health versus healthcareHealth versus healthcare
Question and AnswerQuestion and Answer
Click on “Ask a Question” below this Click on “Ask a Question” below this presentation. Complete the form and click presentation. Complete the form and click “Submit.” “Submit.”
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The Innovations ExchangeThe Innovations Exchange
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http://www.innovations.ahrq.gov/
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#AHRQIX#AHRQIX
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