p40-05-240 designing incentives: the impact of p4p on smoking interventions marc manley, md, mph...
TRANSCRIPT
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P40-05-240
DESIGNING INCENTIVES:
The Impact of P4P on Smoking Interventions
Marc Manley, MD, MPHVice President and Medical Director, Population HealthBlue Cross and Blue Shield of Minnesota
The Fourth National Pay for Performance SummitMarch 10, 2009
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Collaborators
University of MinnesotaLarry An, MDColleen Klatt, PhDBruce Center, PhDJasit Ahluwalia, MD, MPH
Fairview Physicians AssociatesWilliam Nersesian, MD, MPHMark Larson, MBA
Blue Cross and Blue Shield of MinnesotaJim Bluhm, MPHSteven Foldes, PhDNina Alesci, MPHRhonda EvansMarc Manley MD, MPH
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Presentation summary
> Background
> Minnesota quitline collaboration
> Clinic fax research questions and methodology
> Clinic fax referral pilot findings
> Statewide rollout
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Why this matters
>Tobacco use is the leading preventable cause of death
>Tobacco use causes $2 billion in health care costs in Minnesota each year
>Current smokers have 16% higher health care costs
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Comprehensive approach to prevention
Individual
Worksite Community
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The challenge
> Use of telephone quitlines is low
> Earlier recruitment done with media promotion– Advantages– Disadvantages
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Innovations
> Use health plan systems to connect smokers to quit lines– Referrals from disease management, prenatal program, etc.– Pharmacy benefit management system (SCRIPS)– Pay for Performance (Recognizing Excellence)
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Blue Cross quit line - cumulative enrollment 2000-2008
39,320
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
2000 2001 2002 2003 2004 2005 2006 2007 2008
En
rollm
ents
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Clinical Background
> Tobacco use is a chronic medical condition
> Brief interventions are effective, but more intensive interventions are:– More effective– More cost-effective
> Arranging follow-up after the office visit is a particular challenge
> Referral to telephone counseling is an easy way to provide follow-up – Phone counseling increases the odds of successful
quitting by 50-70%
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Clinics and quitlines
> Fewer than 2% of tobacco users in the U.S. use quit line services– Media promotion is needed to encourage calling – Many states offer fax-referral programs, but they are often
underutilized by health care providers
> Multi-faceted interventions improve performance– Systems changes– Leadership– Outreach – Feedback– Incentives
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Clinical practices
HardFollow-up
Easy Fax Referral
HardCounseling
EasyEasyPrescribe meds
EasyEasyInterest in quitting
EasyEasyAdvice to quit
EasyEasyIdentify users
Making it EASYCurrent practiceEvidence-based practice
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The Clinic Fax program
> Builds on a successful collaboration with Minnesota’s Health Plans and ClearWay Minnesota– Successful coordination since 2002– Direct to provider education and mailings
> Minnesota Clinic Fax Program - Centralized Triage System – Clinical referral mechanism for ALL Minnesotans – Led and designed by Blue Cross– Jointly created materials, forms and information
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Clinic Fax referral process
Fax Referral
Patient fills out fax referral, staff create EMR order for smoking cessation and obtain verbal consent
Designated staff fax referral/EMR to Central Triage
Feedback to clinic on result of patient contact
Tobacco status assessed and asked if interested in quitting
Quit line contacts patient
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Clinic Fax referral form (Paper/EMR)
> Clinic information– Pre-populated clinic address and contact– Health care provider
> Patient information– Minimum necessary contact information– Health plan check boxes– Release authorization– Patient signature
> Clinic Feedback– Contact date– Outcome (enrolled, declined, not reached)
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Compliance and confidentiality
> HIPAA Approved Referral Form– Minimum necessary– Collaborator approved– Cover letters
> Aggregate Data Only– By clinic
> De-identified Referrals – Health plan identity removed from reports
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Research questions
> What is the feasibility of establishing an integrated clinic fax referral system in Minnesota?
> What is the effect of financial incentives on the rates of physician referral to a state tobacco quitline?
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Other research questions
– Which clinics respond the most to the incentive?
– Does the offer of financial incentives influence the appropriateness of the referrals?
– What is the cost per additional referral or enrollee?
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Methodology
> Setting: Fairview Physician Associates (FPA)– Large multi-specialty group providing both primary
care and specialty care in Minnesota– A total of 49 clinics provide adult primary care services
and record tobacco use as a vital sign
> Dates: September 1, 2005 – June 31, 2006
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Methodology
> Design: Two-group randomized design– Usual care (feasibility) n=25 clinics
> Information and materials mailed to clinics> EMR modified to allow electronic “fax” referral
– Intervention (n=24 clinics)> Launch meeting> Monthly feedback> Financial incentives
– $5000 bonus for clinics referring at least 50 patients during the study period– $25 for each referral past 50
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Methodology
> Measures– Primary outcome: percentage of smokers referred
to phone counseling– Clinic characteristics– Costs
> Analysis– Unit of analysis: clinic (n = 49)– Primary comparison: 2-sided t-test– Secondary analysis (clinic characteristics): 1- and 2-way
ANOVA
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Results - clinic characteristics
Usual Care (n=25) Enhanced (n=24)
Family Practice 11 13
Internal Medicine 2 2
Ob-Gyn 6 4
Multi-specialty 6 5
1-3 MD 9 6
4-6 MD 8 10
7-18 MD 8 8
No EMR 9 8
EMR 16 16
Very Engaged QI 4 5
Engaged QI 11 11
Less Engaged QI 10 8
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Results – total number of referrals
441
1483
0
200
400
600
800
1000
1200
1400
1600
Usual Care Intervention
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Results - referral rates
11.4*
*4.2
0
5
10
15
Usual care Intervention
Percent
* Statistically significant difference (p < 0.001)
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Results - distribution of clinic by patient referral rates
15
3
6
9
4
12
0
5
10
15
20
25
Usual care* Intervention
Number of clinics
2% >2-10%10% <
* Statistically significant difference (p = 0.002)
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Results - Average clinic referral rates by quality improvement history
15.1 14.1
1.1**3.0
*10.110.1*
0
5
10
15
20
Very engaged Engaged Less Engaged
Level of clinic engagement
Percent
Usual careIntervention
•Statistically significant difference between usual care and intervention clinics
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Results - referral conversion per 100 referrals for intervention vs. usual care clinics
29
47
100
48
28
100
0
20
40
60
80
100
Referred Reached Enrolled
% o
f R
efe
rrals
Usual Care
Intervention
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Cost per referral
Usual Care Intervention
Incentive Costs N/A $70,475
Total Costs $8,937 $95,733
Number Referred
441 1483
Cost per referral
$20 $65
Number enrolled
124 413
Cost per enrolled
$72 $232
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Conclusions
> A fax referral system is feasible (4.2% of smokers referred in usual care clinics)
> Incentives increased referral rates (11.4% vs. 4.2%)
> Incentives appear to be the most beneficial for the majority of clinics with less QI engagement
> No evidence of “gaming the system”
> Cost per caller comparable to media promotion of tobacco quit lines
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Statewide rollout
– October 1, 2007 program launched statewide– Incentive based on enrollment thresholds– 610 clinics registered as of December 2008 – 260 (42%) of sites are participating in
Recognizing Excellence– Average of 310 referrals a month
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Referrals by participation in Recognizing Excellence
38%
59%
31%
31%
32%
10%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Recognizing Excellence Non RE
Per
cent
of c
linic
s .
Referred none Referred 1-9 + Referred10
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