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The Engelberg Center for Health Care Reform at Brookings | The Dartmouth Institute

June 6–8, 2012

Third Annual National ACO Summit

Follow us on Twitter at @ACO_LN

and use #ACOsummit.

Infrastructure for Quality Improvement

Gene Lindsey, MDPresident and CEOAtrius Health and Harvard Vanguard Medical AssociatesACO Summit

Atrius Health

• Non-profit alliance of six leading independent medical groups

– Granite Medical– Dedham Medical Associates– Harvard Vanguard Medical

Associates– Reliant Medical Group– Southboro Medical Group– South Shore Medical Center

• Provide care for ~ 1,000,000 adult and pediatric patients in almost 50 ambulatory sites

• 1000 physicians, 1450 other healthcare professionals across 35 specialties

• Largest physician-based “Accountable Care Organization”

Atrius Health

• 100% on EMR combined with corporate data warehouse, used for managing quality and cost. Patient portal.

• Long history with global payments, currently managing 50% of our patients with global payments across commercial, Medicare and Medicaid populations.

• Strong infrastructure to manage risk

• One of first to sign BCBSMA Alternative Quality Contract (AQC)

• One of 32 Medicare Pioneer ACOs nationally

The concept of an Accountable Care Organization is not new

5

“The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population.”

Dr. Robert Ebert, Founder, Harvard Community Health Plan, 1967

Our Focus is on Achieving Quality

The Triple Aim IOM Definition

• Patient-centered• Safe• Effective• Efficient• Equitable• Timely

• And sustainable

Improve Experience

Of Care

Reduce Per

Capita Cost

Improve Population

Health

Source: IHI.org

Our Challenge is to Move

Volume-basedreimbursement

Value-basedreimbursement

From To

Total Medical Expense

Pricefocus

Physician- centeredsystem

PatientCenteredsystem

Atrius Health ACO Strategies

• Foster culture of quality and service to patient • Strengthen our distributed physician leadership at all

levels in the organization• Continue our LEAN journey to improve quality, patient

safety, patient experience, and reduce costs• Implement & spread Patient Centered Medical Home,

including management of high risk populations• Create compact with staff at every level to clarify roles at

top of license• Strengthen collaboration across specialists, hospitals,

and post-acute care to be successful Accountable Care Organization without hospital ownership

Two Kinds of Change:

Technical• Problem is well-defined• Solution is known, can be

found• Implementation is clear

Adaptive• Challenge is complex• To solve requires transforming

long-standing habits and deeply held assumptions and values

• Involves feelings of loss, sacrifice (sometimes betrayal to values)

• Solutions requires learning and a new way of thinking, new relationships

From Jack Silversin, Amicus

Atrius Health: Challenge of Hospital and ED Information

Hospital Partners

All Hospitals

Most H

ospitals

Monthly Claim

Feed

In 2011, Atrius Health patients visited:

•25 different hospitals with 100+ admissions

•39 different hospitals with 100+ ED visits

10

Robust Data Management Infrastructure is critical

EPIC Suite

Oracle Warehouse Builder (ETL)

CLARITY All PAYER CLAIMS

Quality Management

Practice Management

Encounters / RVU

Browser Smart Client

Tufts Health Plan

Tufts Medicare

BCBSMANeighborhood Health Plan HPHC

Payer Data (Medical Claims,Pharmacy,Member Eligibility)

Clarity Console(ETL)

Medical ExpenseManagement

Patient ExperienceManagement

PATIENT EXPERIENCE

CMSPioneer

Press Ganey

Crystal / WebI / Xcelsius MS Excel/Access

Epic RWB / RADAR

Verisk SMIDxCG/3M APR‐DRG

SPSS

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Tactics to Achieve Quality Measures require clinical interventions across populations

Lean Methodology provides Focus on Adding Value and Use of Common Approach

From Simpler Consulting

Sustainable Primary Care Practice: The Patient-Centered Medical Home

The ‘Medical Home’ is not a place, but rather an approachto providing comprehensive, patient-centered primary healthcare. The Primary Care Physician (PCP) works inpartnership with the patient and family to assure that his/hermedical and health-related needs are met through accessible, coordinated, culturally-sensitive care deliveredon a continuous basis and across all disciplines, settings and services in order to achieve optimum health outcomesand quality of life.

The Medical Home. Pediatrics. 2002; 110; 184-186.

Adaptive Change: We will challenge “Simple rules”

“I am accountable” “We are accountable”

From Accountable Care Organizations, Marc Bard and Mike Nugent, 2011

Problems must be solved by those who do the work

Outstanding Clinician and Staff Experience

• Respect as a basic principle• Communication – weekly email from CEO• Involve the front line in Lean• Site Councils• Leadership Academy• Chief development• Atrius Standard Model for Epic• Governance structure• Go to the Gemba

http://www.harvardvanguard.org/about/news/TopPlacesToWork2009.asp

“In democratic countries, knowledge of how to combine is the mother of all other forms of

knowledge; on its progress depends that of all the others.” Alexis de Tocqueville

Democracy in America

‘Federalist’ Model

Out of Many, One

Leadership Academy

January 2008 (19 participants)

Leadership Academy

September 2008 (33 participants)

Leadership Academy II

January 2009(37 participants)

Leadership Academy III

October 2009(35 participants)

Leadership Academy IV

January 2010(45 participants)

Leadership Academy V

September 2010(37 participants)

Leadership Academy VI January 2011

(38 participants)

L D E EA VD EE LR OS PH MI EP N

T

Evolution of Physician Compensation

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The Value Model:

Group paid mostly for Value,Physicians paid mostly for Value (or salaried)

The Funky Model:

Group paid mostly for Value,Physicians paid mostly for Volume

The Volume Model:

Group paid mostly for Volume,Physicians paid mostly for Volume

The Charitable Model:

Group paid mostly for Volume,Physicians paid mostly for Value (or salaried)

From Craig Samitt, Dean Clinic

Outstanding Quality Measurement

DM Composite Outcomes: LDL control, HbA1c Control, BP control

We have flattened the cost curve for commercial risk patients

Charles HandyThe Age of Unreason

The future we predict today is not inevitable. We can influence it, if we

know what we want it to be…

We can and should be in charge of our own destinies in a time of change.

Reflections…

Track 2: Implementing Performance Measures

Panel 1: Infrastructure for Quality Improvement

Gene Lindsey, MD President and Chief Executive Officer, Atrius HealthJames Fanale, MD Senior Vice President of System Development, Jordan HospitalMarcia Guida James, MS, MBA

CPC Director, Provider Engagement,

HumanaPenny Wheeler, MD Chief Clinical Officer, Allina Hospitals & ClinicsChris Queram, MA President and Chief Executive Officer, Wisconsin

Collaborative for Healthcare Quality (Moderator)

Patient Reported Outcome Measurement: Progress and Promise

Dana Gelb Safran, Sc.D.Senior Vice President Performance Measurement and ImprovementBlue Cross Blue Shield of Massachusetts

Presented at:ACO Summit7 June 2012

29Blue Cross Blue Shield of Massachusetts

Advancing Quality, Outcomes and Affordability: Aligning Member and Provider Engagement Strategies

Reporting to

Providers

ProviderIncentives

Reporting to Public

Member Incentives& Benefits


What are PROMs?

• Measures of a patient's health status or health-related quality of life

• Standardized patient reported data, collected over time in a consistent manner so results can be measured, analyzed, and used in research and care delivery.

• Provides information on key dimensions of patient functional status and well-being; inform diagnosis and treatment decisions.

• Quantifies the impact of treatments in ways that can inform clinical practice and quality measurement.


What are PROMs?

The data collected through PROMs provides clinicians and researchers with information that cannot be identified through a typical clinical indicator or process measure.

11. The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

Yes, Yes, No,limited a lot limited a little not limited at all

a. Climbing several flights of stairsb. Climbing one flight of stairs


Collecting and Using PROMs

Phone/IVR

In-office tablet

Patient Portal

Paper


PROMs in Practice

PROMIS (Patient Reported Outcomes Measurement Information System)• Funded by NIH grant in 2004, PROMIS is a survey item bank of rigorously

reviewed measures of patient–reported health status for physical, mental, and social well–being

• Standardized domains and metrics exist across conditions • The PROMIS initiative is carried out by a network of 12 NIH–funded primary

research sites each with an active study utilizing PROMIS toolsPCORI (Patient-Centered Outcomes Research Institute)

• PCORI was established under the Patient Protection and Affordable Care Act of 2010 (PPACA)

• Mission: to fund research that offers patients and caregivers the info they need to make informed healthcare decisions

• Accelerating patient-centered research is one of five PCORI research prioritiesPROMS in the U.K.

• Starting on April 1, 2009 all providers of NHS-funded care have been required to collect PROMs for these four clinical areas: hip replacement, hernia surgery, knee replacements, varicose vein surgery

• From 4/11 to 12/11, 131,000 pre-op and 50,000 post-op PROMS surveys completed

• 87.7% of hip replacement respondents and 79.4% of knee replacement respondents recorded an increase in their general health following their operation (EQ-5D index)


PROMIS Domains


Meaningful Use Phase 2 (Final Rule Pending)

CLINICAL QUALITY MEASURES PROPOSED FOR MEDICARE AND MEDICAID ELIGIBLE PROFESSIONALS INCLUDES PROMS BEGINNING CY 2014

Functional status assessment for:

• Knee replacement

• Hip replacement

• Complex chronic conditions


Pathway to Accountability for PROMs

Phase IIPopulation level uses such

as shared decision making

Phase III

Accountability for outcomes

Phase I

Initial integration into practice workflow and

culture

PROM Development: Continued extensive psychometric and evaluative science needed to understand how and when PROMscan be used for “accountability.”


Near- and Longer-Term Promise of PROMs

Patients and Families• Improved clinical interactions• Empirical basis for treatment decisions• Meaningful data on “quality” to inform choice

Clinicians/Systems• Monitor patient progress• Data to guide treatment decisions• Improved evidence-base for care• Compete on evidence of better results

Payers/Purchasers• Tools to promote focus on health and health outcomes• Improved evidence base on efficacy and basis for informed decision making• Ability to measure and improve outcomes

PROMs


[email protected]

For More Information

Track 2: Implementing Performance Measures

Panel 2: Implementation Path to Patient‐Reported and Outcomes

MeasuresDana Safran, ScD Senior VP for Performance Measurement and Improvement, Health Care Services Division, Blue Cross Blue Shield of Massachusetts, Associate Professor of Medicine, Tufts University School of MedicinePhil Polakoff, MD, MPH, MEnvSc Managing Partner, Polakoff/BolandFranklin E. Bragg, MD, FACP Primary Care Quality Assessment and Performance Improvement Activities Coordinator, Eastern Maine Medical CenterJennifer L. Jackman Senior Vice President, Accountable Care, Monarch HealthCareMark McClellan, MD, PhD Director, Engelberg Center for Health Care Reform, Brookings Institution (Moderator)

The Engelberg Center for Health Care Reform at Brookings | The Dartmouth Institute

June 6–8, 2012

Third Annual National ACO Summit

Follow us on Twitter at @ACO_LN

and use #ACOsummit.

the engelberg center for health care reform at … simpler consulting sustainable primary care...

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