optimizing appropriate use at partners...
TRANSCRIPT
Optimizing Appropriate Use at Partners HealthCare
April 13, 2015 Creagh Milford, DO, MPH, Associate Medical Director, Partners HealthCare Population Health Management
Michael E. Zalis, MD, Chief Medical Officer, QPID Health, Inc.
DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.
Conflict of Interest Creagh Milford, DO, MPH Salary: None Royalty: Yes Receipt of Intellectual Property Rights/Patent Holder: Yes Consulting Fees (e.g., advisory boards): None Fees for Non-CME Services Received Directly from a Commercial Interest or their Agents (e.g., speakers’ bureau): None Contracted Research: None Ownership Interest (stocks, stock options or other ownership interest excluding diversified mutual funds): None Other: N/A
© HIMSS 2015
Conflict of Interest Michael Zalis MD Salary: yes Royalty: none Receipt of Intellectual Property Rights/Patent Holder: yes Consulting Fees (e.g., advisory boards): none Fees for Non-CME Services Received Directly from a Commercial Interest or their Agents (e.g., speakers’ bureau): none Contracted Research: none Ownership Interest (stocks, stock options or other ownership interest excluding diversified mutual funds): stock options, QPID Health, Inc. Other: n/a
© HIMSS 2015
Learning Objectives Evaluate your organization’s processes and systems for attesting to appropriate use of surgical procedures with respect to the Partners HealthCare case example. Identify areas for improved workflow and clinical outcomes from applying best practice guidelines and activating clinical intelligence Calculate return on investment from reducing administrative costs of prior approval
Value Achieved in Multiple STEPS
STEP Category Benefit Achieved through Q-Guide Program
Satisfaction (Patient, Provider, Staff…)
Making it easy to apply evidence-based guidelines to the patient’s case improves provider and patient satisfaction
Treatment/Clinical (Safety, Quality…)
Increased appropriate use of procedures drives better outcomes and protects patients
Electronic Information (Increased use of guidelines…)
Incorporates best practice guidelines from the literature as decision algorithms
Prevention and Patient Education Savings (Efficiency, Operational) Eliminates administrative burden of prior
authorization, and removes treatment and scheduling delays
5
I. Background
II. Assessing procedural appropriateness
III. Consensus process: Lumbar spine surgery
IV. Progress to date
V. Redesigning prior authorization
VI. Emerging lessons
6
Agenda
What is the problem? 1. Providers can’t easily quantify the number of procedures we perform
that are consistent with best medical practice – We assume appropriateness of procedures is high because of the
quality of our physicians.
2. External stakeholders (payers, regulators and some patients) often suspect that providers overuse procedures – Frequent publications present data indicating overuse and reliance on
payer-based prior authorization.
3. Best practices for informed consent and shared decision making have evolved over the past decade – Incorporating communication tools into daily practice has proved
challenging.
7
• Better Patient Care: It’s the right thing to do for patients
• Lower Cost: Now that providers accept financial risk, they are responsible for overuse and appropriate use
• Less Administrative Work: Payers are willing to use Q-Guide as a substitute for prior authorization
• Regulatory Requirement: Providers are required to report appropriateness to
state and federal registries (MassDAC, STS, ACC, NSQIP)
• Marketable: Providers don’t currently promote or market our high levels of appropriate procedures
8
Additional benefits of addressing procedural appropriateness
Payers’ perspective: Spinal fusion
“Spinal fusion is one of the top 10 procedures that most
payers are looking at the rate of increased utilization,
aggregate spending and the likelihood of continued
increases based on demographics.”
Sean Tunis, CEO of Center for Medical Technology Policy in
Baltimore
10 http://www.albany.edu/news/46288.php
What does the public really know about providers rates of appropriate procedures?
How should providers respond? Demonstrating Appropriateness
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
AMC NY
Rarely Appropriate
Maybe Appropriate
Appropriate
Appropriateness Scores for Diagnostic Catheterization for Suspected CAD at AMC* vs. NY Cardiac Database**
n=8986 n=517
*MGH Data reflect the time period 8/2013- 8/2014. **Hannan, EL, et al. Appropriateness of Diagnostic Catheterization for Suspected Coronary Artery Disease in New York State. CIRC INTERVENTIONS. January 28, 2014. 113.000741
Median hospital-level inappropriateness rate is 28.5%*
ROI: AMC Data collection and
reporting ~1 hour, NY ~3 years
Patient with a
Surgical Problem
Assess Appropriateness
Criteria
Schedule OR
Procedure Recovery Physician Encounter
Possible Need for
Procedure
Shared Decision Making
Pre-Procedure
Testing
Short-term Outcome Measures
Long-term Outcome Measures
Personalized Risk
(Consent Form)
Informed Consent
PROs Survey(s)
The Patient Journey
PROMs Q-Guide
Milford CE, Hutter MM, Lillemoe KD, Ferris TG. (2014). Optimizing appropriate use of procedures in an era of payment reform. Annals of Surgery 206(2): 202-204
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What is Q-Guide?
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Guidelines and best practices
Procedural Risks and Benefits
Summary Assessment
Outputs
Prior authorization form(s)
Documentation in Electronic Health
Record
Personalized patient consent
form Evidence based medicine using
recent guidelines,
publications, and consensus
Quantitative patient-specific risk models for peri-operative
and post-operative risks
Appropriateness scores
Specific risks and benefits
Patient
preference
Shared decision making materials
+ =
Lumbar Spine Procedure - Intervention Page
Powered by QPID
Lumbar Spine Procedure - Stenosis Indication
Powered by QPID
Lumbar-Spine Procedure – Risks Page
Powered by QPID
Lumbar Spine Procedure – Clinical Summary Page
Powered by QPID
Lumbar Spine Procedure – Assessment Page
Powered by QPID
Lumbar Spine Procedure – Consent Form
Powered by QPID
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How Patient Data is Extracted and Assembled
API
Fact
Extractor
NLP
Machine Learning
Apps Patient
Data Model (PDM) Admin Data
Structured Data
Unstructured Data
Clinical Content
SQRL Query Engine
Scanned Data
Powered by QPID
By December 2015, Q-Guide will assess 9 of the 20 most costly procedures
Nationally, these 9 procedures account for
$64 billion, or 63% of the total costs of the 20 most costly OR procedures in
the US: • Spine fusion • Spine laminectomy • Knee arthroplasty • Hip replacement • PCI • CABG • Heart valve repair/replacement • AICD implantation • Hysterectomy
Prior Auth is a Burden on our Physicians
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Source: The Fruit Street Physician, September 2014; 23(8) http://mgpo.partners.org/
Our experience has shown thus far that it is possible to collaborate with payers to redesign the prior auth process. Payers are conducting evaluations to assure themselves that Total Medical Expense doesn’t increase.
Response rate = 96% of 1,900 physicians
Pilot dates: September 8, 2014 to present
Focus: Lumbar spine procedures (fusion, laminectomy, discectomy, or non-operative management)
Highly collaborative process including Ortho Spine, Neurosurgery, and expert consensus panels at two academic medical centers.
PROMs are incorporated into Q-Guide
Goals of the pilot are:
To maximize the % of spine surgeries that are appropriate
To reduce the administrative burden associated with Prior Authorization
Implementing the Patient Pathway: Q-Guide + PROMs pilot
Creation of and adherence to clinical guidelines
Efficient administrative process
Patient-centered care (personalized risks and consent forms)
For these pilots, we focus on our core strategy:
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Overview of the consensus process: i.e. lumbar spine
1. Multidisciplinary consensus on indications
2. Create decision support logic
I. Close collaboration with payer to identify procedure • Includes payer and provider clinical and
administrative leadership
II. Developed clinical guidelines and scoring criteria • Requires subject matter expert input
III. Created Expert Advisory Panel to provide feedback
• Vetting with interdisciplinary experts
IV. Obtained consensus with Payer • Participation with administrative and clinical
experts
V. Beta testing • Providers test the application and provide
feedback
Overview of the consensus process: i.e. lumbar spine
Green: Consensus on guidelines
Yellow: Inconsistent data led to treatment equipoise
Red: Insufficient outcomes and evidence
Once we agree on the indications, we
use a modified RAND approach to
gain consensus based on specific clinical scenarios
1. Multidisciplinary consensus on indications
2. Create decision support logic
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Q-Guide Algorithm for Lumbar Spine Surgery
Indication- Disc Herniation with Radiculopathy
Progress (September 2014 - March 2015)
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• Pilot dates: Sept 8, 2014 – March 3, 2015
• Active pilot sites: – MGH Ortho/Spine – MGH Neurosurgery – BWH Ortho/Spine – BWH Neurosurgery
• Q-Guide assessments completed:
– 95 total (49 at MGH; 46 at BWH) – 87% appropriate, 7 rarely appropriate
cases under review
• Patients receiving decision aids: 71%
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Appropriateness breakdown
05
1015202530
Def
orm
ity
Dis
c H
erni
atio
n (e
xclu
des
Cau
da E
quin
a S
yndr
ome)
…
Dis
c H
erni
atio
n an
d R
ecur
rent
Her
niat
ion,
with
Rad
icul
opat
hy
Isth
mic
Spo
ndyl
olis
thes
is
Lum
bar L
amin
ecto
my
Met
asta
tic T
umor
Pse
udar
thro
sis
Spi
nal S
teno
sis,
Rec
urre
nt/R
esid
ual…
Tum
or
MGH
BWH
Procedures by Indication
7 5
83
0
10
20
30
40
50
60
70
80
90
100
PHS
Appropriate
May Be Appropriate
Rarely Appropriate
Review • Peer-review of case and
rationale for proceeding
Document • Document in EHR that the
case is reviewed
Proceed • Proceed with the case (per clinician decision)
Revise • Based on consensus, revise guidelines when
appropriate
Monitor • Ongoing monitoring
Process for documenting and reviewing “rarely appropriate” cases
28
Traditional Prior Auth Q-Guide System
1:1 review with payer Process to review denials/ rarely
appropriate cases
Provider peer review
1 hour Time spent <10 minutes
Not flexible (annual) Flexibility in making changes to guidelines
3-4 weeks
Possibly Delayed/Canceled case No
Process:
Benefits:
User feedback on new prior authorization process
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“My office staff, me, and my PA all feel that the process has been greatly improved with Q-Guide.” Physician
“...it’s going well and it is easier than the Smartsheet process.” Admitting department
“the surgeries that we’ve scheduled are getting approved without a problem...”
Frontline administrative staff in clinic
“The authorization process is working smoothly.” Payer operations
“The pilot process made it clear that our goals in achieving cost effective quality
health care are aligned and that through working together we can understand each other’s “pain points” as we develop shared solutions.” Payer leadership
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Current prior authorization process
Clinical Office
Admit-ting
Payer
Patient visits surgeon and lumbar laminectomy is indicated
Surgeon schedules procedure
Admin knows procedure requires PA?
Admin faxes form to admitting
Admitting checks for form
Admitting submits PA
PA reviewed by third party
Decision submitted to Admitting Manually
appeal claim
Admitting enters auth # in PATCOM
Patient undergoes procedure
Admitting checks for form
Admitting calls clinic to work through PA form
No
Yes
Denied
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Creating a more efficient prior authorization process Clinical Office
Admit-ting
Payer
Patient eligibility confirmed
Q-Guide assessment completed. Consent form generated.
Admin staff print Q-Guide Authorization form* and fill in ICD-9 and CPT codes.
Prior authorization granted upon receipt of Q-Guide form
Confirmation received within 1-3 days
Admitting documents auth # in system
Q-Guide form uploaded to LMR/sent to Admitting
Q-Guide form verified and faxed to Payer
Physician Admin staff
Potential savings: • Current vs new process:
o Clinical Office: 4-5 steps vs 3 steps o Admitting: 4 steps vs 3 steps o Payer: 2 steps vs 1 step
Progress: Adoption for all procedures
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85% of assessments completed across all procedures are
‘appropriate’
Challenge #1: Integrating with practices
33
MD
MD, Fellow, or PA
Total Time
40 min
14 min 30 sec
5 min 60 minutes
30 sec 30 sec Total Q-guide
Time = 90 Seconds
2% of Patient
Encounter
Time (in
minutes)
Discussion with patient
Physical exam and
explanation of procedure
Q-guide Guidelines
Q-guide Risks
Q-guide Assessment
Consent
Events in patient encounter
Total Visit Time
Our goal is for providers to be able to complete Q-guide assessments in two
minutes or less
Challenge #2: Continuously updating guidelines and risk models
Should be green
Can we keep up with specialty society
guideline revisions?
Emerging lessons from the front lines
35
• Payer and providers can successfully collaborate to reduce administrative burden
• Engaging your key stakeholders, including clinical and administrative leadership, is critical to success
• Communicating the appropriateness value proposition to providers is challenging if not participating in an ACO or shared savings plan
• Documenting clinical decision making at the point of care can potentially mitigate unnecessary surgeries
• Standardized presentation of surgical and non-surgical treatment alternatives promotes shared decision making and engages patients
• Requires significant capital and IT infrastructure (including data and analytics)
• Requires management expertise
“Imagine the impact on patients when I have them watch the computer screen and walk through their current
clinical situation, their individual risks of various treatment options (medical treatment, surgery, and catheter-based
therapy), receive a ‘score’, and then participate actively in the decision? It is incredible to watch how much more
involved they are in the decision.”
-Dr. Michael R. Jaff Paul and Phyllis Fireman Chair in Vascular Medicine
Medical Director, Vascular Center, Massachusetts General Hospital
Professor of Medicine, Harvard Medical School
Physician testimony
