Richard E. Ward, MD, MBA VP, Clinical Programs and Medical

Informatics

Charles Carpenter Director, Medical Advantage Group

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Partnering for Value as Bridge to Future

Current State

Next Generation PPO Concept •  Stronger role for primary care (medical home, not gatekeeper) •  Providers at some risk (gain-sharing, not capitation)

Partnering for Value

Quality Improvement, Cost Savings and Market Leadership Enhances Competitiveness

Short- Term Value

Foundation for Future

Preparations

•  Physician market organized into effective physician organizations

•  Established definitions of care responsibility based on

populations •  Strong data pooling, analysis,

reporting •  Providers have sophistication

regarding managing based on data and metrics

•  Providers have trusting relationship with BCBSM

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3

Physicians Hospitals

Hospital Incentive Program

(in Participating

Hospital Agreement)

BCBSM Value Partnerships

CQIs: Collaborative Quality Initiatives

BMC2: BCBSM Cardiovascular Consortium Angioplasty Collaborative Quality Initiative

Michigan Surgical Quality Collaborative

Michigan Bariatric Surgery Collaborative

Michigan Breast Oncology Quality Initiative

Michigan Society of Thoracic Surgeons Cardiac Surgery

Collaborative Quality Initiative

PGIP: Physician Group

Incentive Program

Prof-CQI: Lean Thinking Clinic Re-

engineering Consortium

Prof-CQI: Michigan Anticoagulation

Quality Improvement Initiative

Advanced Cardiac Imaging Consortium

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PGIP Development & Expansion 2005 2006 2007 2008 2009 2010

Launch PGIP

Restructure PGIP

Add pmt for pt-self mgmt educ/training

Add 6 PCMH initiatives

Add Transparency

Add 6 more PCMH initiatives

Add PCMH designation

Integration with Blue Health Connection

Organized Systems of Care

Physician Organizations

12 31 33 (plus 50 sub-POs)

35 (plus 50 sub-POs)

36 (plus 50 sub-POs)

Physicians 2,903 4,798 5,980 6,657 7,618 5,532 PCPs=73% 2,086 Spec=27%

Members 609,704 1,159,861 1,541,165 1,687,524 1,772,598

Specialties Added

Cardiology Immunology

Medical Oncology Hematology Pulmonology

Radiology Hospitalists Nephrology

Ob/Gyn

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PGIP Quarterly Meeting

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Ad Hoc Projects Interest Groups

Leadership Committees Initiatives (Core Teams)

Physician Group Incentive Program (PGIP) Organizational Model

Primary Care

Medical Oncology

Improvement Capacity Initiatives 1

Condition Category Initiatives 2

Service Category Initiatives 3

Core Process Investment Initiatives 4

Provider Improvement Infrastructure Initiatives 5

Self Management

Systems Integration

Advanced Medical Home and Planned Care Visits

Organizational Functions

Academic Detailing/ Regulation Pharmacists

Michigan PGIP Analytic Consortium (MPAC)

(hosted by U of Mich)

Hospitalists

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Improvement Capacity Initiatives •  Establishing staff dedicated to managing process improvement teams (new PGIP groups only) •  Establishing analytics and reporting staff (new PGIP groups only)

Condition-focused Initiatives •  Oncology/ASCO Quality Oncology Practice Initiative™ (P-CQI ~ limited participation) Service-focused Initiatives •  Increase the use of generic drugs •  Radiology procedures utilization •  ER Utilization •  Inpatient Utilization •  Michigan Anticoagulation Quality Improvement Initiative (MAQI2) (P-CQI ~ limited participation) Core Clinical Process-focused Initiatives •  Evidence based care tracking •  *Performance reporting •  *Patient-Provider agreement •  *Extended access •  *Individual care management •  *Test tracking and follow-up •  Lean Thinking-Clinic Re-engineering CQI (P-CQI ~ limited participation) Clinical IT-focused Initiatives •  *Accelerating the Adoption and Use of Electronic prescribing •  *Patient registry •  *Patient Portal *Components of the Patient Centered Medical Home (PC-MH)

2

3

4

5

1

PGIP Initiatives

•  *Coordination of Care •  *Preventive Services •  *Specialist Referral Process •  *Linkage to Community Services •  *Self-Management Support

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Each PO has its own strategy for practice transformation

*(Change between 2008 and 2009)

PGIP Initiatives related to Patent-Centered Medical Home

Year Launched

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Patient Centered Medical Home

PCP PCP

PCP

PCP

PCP PCP

PCP

PCP

PCP PCP

PCP

PCP

PCP

PCP

PCP PCP

PCP PCP

PCP PCP

PCP

PCP

PCP PCP

PCP

PCP PCP

PCP

PCP PCP PCP

PCP

PCP

PCP

PCP PCP

PCP PCP

PCP

PCP

PGIP Phys Org A

PGIP Phys Org B

PGIP Phys Org C “Control Group”

PC-MH Nominee

PC-MH Nominee

PC-MH Nominee

PC-MH Nominee

PC-MH Nominee

PC-MH Nominee

10

Patient Centered Medical Home

PCP PCP

PCP

PCP

PCP PCP

PCP

PCP

PCP PCP

PCP

PCP

PCP

PCP

PCP PCP

PCP PCP

PCP PCP

PCP

PCP

PCP PCP

PCP

PCP PCP

PCP

PCP PCP PCP

PCP

PCP

PCP

PCP PCP

PCP PCP

PCP

PCP

PC-MH

PC-MH

PC-MH PGIP Phys Org A

PGIP Phys Org B

PGIP Phys Org C “Control Group”

PC-MH Nominee

PC-MH Nominee

PC-MH Nominee

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BCBSM Patient-Centered Medical Home Designation

•  Physician Organizations nominated 44% of their PCPs •  Calculated a single weighted PCMH score for each practice unit

–  50% for Self-reported PCMH Capabilities –  50% for Performance

•  Evidence-Based Care/Preventive Services •  Use of Generic Drugs •  Use of ER for Primary Care Sensitive Conditions •  Use of Low Tech & High Tech Imaging

•  PO leaders reviewed preliminary scores and revised nominees list •  Developed “Interpretive Guidelines” regarding PCMH capabilities •  Over 100 validation site visits •  Review calls with PO staff to ensure consistent self-reporting of PCMH

capabilities

* Based on NYU algorithm classifications: Non-Urgent; Urgent but Primary Care Treatable; ED Needed but Avoidable)

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BCBSM Patient-Centered Medical Home Designation

•  BCBSM designated 300 Primary Care Practices –  1,200 Physicians, representing

25% of PGIP PCPs) –  Effective July 1, 2009 through June

30, 2010

•  Held Celebration Receptions in different parts of State

•  Published information about designees on BCSBM.com

•  Designated PCMH Practice Units receive increase in reimbursement for evaluation and management services

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BCBSM PCMH Designation not Geographically Uniform

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What are PGIP participants doing to transform care processes?

•  Implementing new information technologies –  Chronic Disease Registries –  E-Rx –  e-Laboratory access and management –  EMR with clinical decision support

•  Adding practice improvement coaches and data analysts at physician organization

•  Adding care managers and patient educators at practice unit or physician organization –  RNs –  Certified Diabetes Educators –  Registered Dieticians –  Mental Health Specialists –  Exercise Physiologists –  Clinical Pharmacists

•  Participating in practice transformation collaboratives –  Lean Workshops –  Improving Performance in Practice (IPIP) –  TransforMED –  IHI Learning Collaborative

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LEAN Process Improvement •  PGIP rewards for Lean Coordinating

Center at U of Michigan (established June, 2008)

•  PGIP rewards for 10 participating PGIP POs

•  1 PO applied PGIP reward to training an internal Lean Coach

•  Care Delivery Processes addressed: •  Preparation for patient visits •  e-Prescribing •  Test tracking •  Patient self management education and

training •  Diabetes care

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LEAN Process Improvement

Improving Diabetes Care Process using Lean

PGIP Performance on Evidence Based Care Delivery 2005 through 2Q09

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PGIP Performance on Prescribing Generic Drugs

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Evaluating PGIP Radiology Initiative Using Mixed Procedure Model 2008Q4 – 2009Q3, n=952K members

Minimum Maximum

-$1.85 $1.33

$5.34 $11.58

$3.63 $12.21

-$0.87 $9.32

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Patients in Practice Units participating in PGIP PCMH Initiatives are receiving superior care

For example: 60% of members in “Participating Practices”

have 24/7 access to care, as compared to 25% of members in “Non-Participating Practices”

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BCBSM PCMH Designees have capabilities consistent with the PCMH vision •  45% regularly generate preventive services reports on all

patients in their registries •  68% systematically provide action plan development and self-

management goal setting for at least 1 chronic condition (e.g., all patients with diabetes)

•  35% systematically provide action plan development and self-management goal setting for all chronic conditions

•  85% monitor patients’ gaps in care, and •  74% provide planned visits, for at least 1 chronic condition

(e.g., patients with diabetes) •  43% provide planned visits for patients with any chronic

condition

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BCBSM PCMH-designees have more favorable risk-adjusted utilization and standard cost profiles

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Current State

•  Employers expect health plan to deliver wellness and care management services

•  Health Plans and Wellness & Care Management Vendors have always talked about the importance of “integration with providers”

•  But, typical concept of “integration” is –  Encouraging providers to refer patients to health

plan’s coaches –  Sending “gaps in care” reminders

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Opportunity •  Care Management can be more effective if:

–  It is delivered in the context of the doctor-patient relationship –  It is fully integrated into the medical plan of care –  It can be delivered with the benefit of a face-to-face interaction –  It can be integrated into the core clinical processes of the patient-

centered medical home

•  Ideally, local staff deliver care mgmt services –  Primary care clinic / PCMH –  Physician organization –  Other community resources

•  It is impractical to place health plan or vendor staff in each primary care clinic location

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Opportunity

•  BCBSM has assets that can be leveraged to achieve integration with provider’s care processes –  Large practice share –  Strong collaborative relationships –  Existing connectivity –  Already paying for T-codes for patient self-management

education and training –  Already have PGIP PCMH initiatives in place to incentivize

physician organizations for implementing the chronic care model and developing care coordination capabilities

–  Already have PCMH designation program in place to reward PCMH practice units

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Goal

•  25% of BlueHealthConnection care management services delivered by providers within 4 years (starting one year ago)

•  Intervention compatibility across settings •  Data integration to support evaluation and

reporting

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Integration of BlueHealthConnection and PCMH Physician Organization Partners

•  Henry Ford Medical Group –  Kathy Scher

•  Genesys Integrated Group Physicians –  Cathy Heiman, Ann Donnelly

•  Integrated Health Partners –  Ruth Clark, Mary Ellen Benzik, MD

•  University of Michigan Health System –  Jean Malouin, MD

•  West Shore Health Network –  Paul Ponstein, MD, Jenn Bailey

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Approach •  Reward physician organization participation in development

process as a PGIP project

•  Program needs to be established and proven to be operationally successful before incorporating into product offerings

•  POs and BCBSM’s Clinical Program Development team collaborate to design one or more models of Provider Based Care Management integrated with BlueHealthConnection

•  Establish PGIP project pilot test the models to determine effectiveness and feasibility

•  Timeline: Pilot to start April, 2010

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Roadmap •  Pilot: Adapt existing WCM Components

– Chronic condition management – Care Transitions

•  Then collaborate to develop new WCM Components – Oncology care management program – Pain management program – Depression management in primary care – Enhanced discharge planning and coordination with

primary care – High-risk maternity program – End of life palliative care

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Information Technology Integration •  Maintenance of Metadata

–  PGIP provider data –  Care Relationship data –  Provider capabilities and preferences regarding provider-based care mgmt processes –  “Hub logic” regarding WCM targeting in response to events

•  Bi-directional Notification of Events –  Changes is data (risk scores, disease ids) –  Care Transition Events (e.g. transition from home to hospital and from hospital to

home) –  Care Relationship Transition Events (e.g. member picks a PCP, claims-based

attribution logic asserts the existence of a care relationship, provider invalidates a care relationship)

•  Sharing Health Plan Data –  Eligibility –  Member Health Record Summary Document, incl Reminders/Alerts

•  Capturing Data into Clinical Program Operational Data Store (CPODS) –  Activities –  Care Plan –  Results

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Key PGIP Themes: 2010 and beyond

Organized Systems of Care (aka Accountable Care Organizations)

–  Recommended Reading: “How to Create Accountable Care Organizations” by Harold D. Miller. (www.CHQPR.org)

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Ref: “How to Create Accountable Care Organizations” by Harold D. Miller. (www.CHQPR.org)

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Goals of Payment Reform

Ref: “How to Create Accountable Care Organizations” by Harold D. Miller. (www.CHQPR.org)

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BCSBM Initial Plan for Organized Systems of Care

•  2010 –  Collaborate with PGIP physician organizations to define concepts –  Conduct analysis of network practice and referral patterns to

establish empirical approach to defining Systems of Care –  Compare empirically-defined and self-defined Systems of Care –  Report PGIP performance metrics by Systems of Care

•  2011 Goal –  Establish BCBSM designation program for Organized Systems of

Care –  Transparency: Public reporting of OSC performance metrics and

designation –  Payment Changes to reward designated OSC

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Multiple Sources of Revenue for PCMH