9/3/2013. Understanding Data: How to improve quality and affordability. Disclosure Information. Overview

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1 Understanding Data: How to improve quality and affordability MGMA 2013 Annual Conference October 8, 2013 Robert A. Greene, MD National VP, Clinical Analytics Final Disclosure Information Meeting: Speaker: MGMA 2013 Annual Conference October 8, 2013 Robert A. Greene, MD Disclosure of Relevant Financial Relationships I have the following financial relationships to disclose: Stockholder in: UnitedHealth Group Focused Medical Analytics, LLC Employee of: The health plan, UnitedHealthcare, which is part of UnitedHealth Group Disclosure of Off-Label and/or investigative Uses I will not discuss off label use and/or investigational use in my presentation. 2 Overview The Problem: Quality and Cost Variation Quality Improvement and the Measurement Process UnitedHealthcare Drives Value through Aligned Programs Integrated Programs Incentives for Patients What Physicians and Practices Can Do to Demonstrate Value 3 1

2 The Health Care Landscape Unsustainable Spending Trends & Quality Gaps Healthcare costs continue to rise and are unsustainable Healthcare cost growth exceeds workers earnings increases by 3-4x $2.6T in annual healthcare costs, which is more than three times the $714 billion spent in An estimated 1/3 rd of this spending is duplicative or wasteful. Inappropriate utilization of hospitalizations Patients suffer a 6% complication rate for every day of hospitalization 98,000 people die prematurely in hospitals every year 20% Readmission rate, which results in more costly care and complications, including a higher risk of hospital acquired conditions & infections In 2000, 914,000 treatment complications cost $19 billion Variation in care Recommended care is being delivered 55% of the time Case-mix adjusted hospital death rates vary 400% Dartmouth Center for Evaluative Clinical Sciences estimates that 30% of Medicare spending is wasted We have the opportunity and responsibility to address the Triple Aim of: Better Care, Better Health, Lower Costs 4 Table 2: Median Price and Ratio of Maximum to Minimum Price for Selected High-Volume DRGs, Contemporary Context Rapidly changing business models: From traditional insurance focus on risk & forecasting to highvalue care facilitation New regulatory scheme post-aca: health care more of a commodity Consumer in the driver seat Key payer strategies: Network Configuration, Payment Reform, Medical Management, Care Management, Transparency, Consumer Engagement, Product Innovation Strategic Partnerships with Physicians and Delivery Systems Retaining Insurance Risk, sharing/spreading/incenting Performance Risk In some cases, more direct care delivery 6 2

3 The New Yorker On Health Care Costs: Discussions of health care in the U.S. usually focus on insurance companies, but, whatever their problems, they re not the main driver of health-care inflation: providers are. Hospital stays, MRI exams, drugs, and doctor s visits are simply more expensive here than they are elsewhere, and the fee-for-service structure insures that we use more of them, too. Source: James Surowiecki New Yorker 5/2/11 M3RHiaHz 7 All quality improvement requires three basic elements 1. A Goal 2. A measure of how far you have to go to get there 3. An idea for how to get there (QI ideas are for another time) 8 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. Why We Do What We Do Achieving the The Triple Aim! The root of the problem in health care is that the business models of almost all US health care organizations depend on keeping these three aims separate. Society, on the other hand, needs these three aims optimized (given appropriate weightings on the components) simultaneously. Improve individual experience Improve population health Tom Nolan, PhD, Don Berwick, MD, MPH Control inflation of per capita costs Triple Aim The Triple Aim: Care, Health, And Cost, Health Affairs, 27, no.3 (2008): Donald M. Berwick, Thomas W. Nolan and John Whittington 9 3

4 Restating the Triple Aim: Increasing Value Improved health (Outcomes) Improved care (Patient experience outcome) Decreased costs Rearranged: Value = Outcomes/Costs 10 Copyright 2012 American Medical Association. All rights reserved. The measurement process has several steps Data Measures Analysis Reporting Deployment Claims Patient reported outcomes Registries Example: Post Dr. Smith s operative rate of complications complications Bleeding after back Infections surgery Here is your rate of complications Here is a comparison rate Public display Value based benefits Pay for performance Value based contracting 11 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. What first? Measures! Data Measures Analysis Reporting Deployment Claims Patient reported outcomes Registries Post op complications Bleeding Infections Dr. Smith s rate of complications after back surgery Here is your rate of complications Here is a comparison rate Public display Value based benefits Pay for performance Vl Value based contracting 12 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. 4

5 Donabedian quality measure framework Structure: the attributes of settings where care is delivered Process: whether or not good medical practices are followed Outcome: impact of the care on health status Structure Measure: I have a back surgery registry Process Measure: I check the instrument count Outcome: My patients have a complication rate < 1% Donabedian framework, from Michael J. McQuestion, Quality of Care. Johns Hopkins Bloomberg School of Public Health, Accessed 7/29/ Outcome measures are preferred A priority among measure developers (National Quality Forum) Need risk adjustment Can be derived from claims data (with limitations) Logistics (cost and effort) may limit other sources Patient reported outcomes Registries Chart extract Where do these measures come from? The National Quality Forum: Extensive vetting process leading to endorsement of measures developed by others Helps set strategy Calls for measures to fill gaps (e.g. outcome measures) AQA: Ambulatory Quality Alliance NCQA: Healthcare Effectiveness Data and Information Set (HEDIS) measures AMA PCPI: Physician Consortium for Performance Improvement CMS CDC Specialty societies and many others 5

6 To assess value, you also need to measure the denominator It s not just quality you must think about costs and utilization! NQF has endorsed measures for Total cost of care Total resource use (i.e. standardized cost) Costs specific to the program/project of interest t Utilization rates Related to the program/project of interest Emergency room visits and admissions as measures of the success of outpatient care in Camden, NJ* Note: Rate of defects, such as readmissions, are quality measures as well 16 * Atul Gawande. The Hot Spotters. The New Yorker, 1/24/2011. Adapted from a quote of Dr. Jeffrey Brenner. Build the rest of the measurement process to support your goal Data Measures Analysis Reporting Deployment Second: FIRST START Find/choose HERE data source(s) to support your measures Claims Patient reported outcomes Registries Other Third: Choose analysis, reporting and deployment to support your goals Think about deployment in parallel Here is your rate of complications Here is a comparison rate Public display (publicity) Quality Improvement Value based benefits Pay for performance Value based contracting Etc. 17 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. Examples from UnitedHealthcare Aligned Programs UnitedHealth Premium physician designation program Public reporting (performance transparency) Value-based benefits myhealth Cost Estimator: price transparency View360: Prospective information for physicians 18 6

7 UnitedHealthcare Drives Value through Aligned Programs Integration across our Network, Product and Clinical Programs and Innovations Drives Value for our Customers and Consumers. Care Management Programs Transparency and Premium Designation Program High Performing Preferred Networks Value-based Benefits Value-based Contracting High Quality V A L U E Low Cost 19 How UHC Helps Address Unwarranted Variation in Quality/Costs Provider-Focused Tools Pre-service / Concurrent / Retrospective Review and High-performance Networks, incl. Centers of Excellence Physician Education Delivery System Innovation, such as Patient-Centered Outpatient, Inpatient, and Pharmacy Utilization Review Medical Homes and ACOs Physician and Hospital Performance Measurement Electronic Medical Records, apply Meaningful Use Physician and Hospital Quality Improvement Programs Electronic Prescribing Value-based Provider Payments Health Information Exchanges Core Tools Evidence-based Medicine Benefit Plan Design Medical Necessity Clinical Guidelines and Medical Policies Coverage Determination Guidelines Appeals and Grievances for Members and for Providers Medical Technology Assessment Member-Focused Tools Provider- and Member- Focused Tools Health and Wellness Programs Health Care Information Technology Case Management Sophisticated Clinical Analytics to Identify Gaps in Disease Management Care and in Affordability Care Coordination Collaborative Measurement Projects, using Multi- Transparency of Physician and Hospital Performance Payer Claims Databases Assessments Administrative Simplification through Automation Consumer-directed Incentives for Healthier Behavior Value-based Benefits, including Tiered Benefits & Reference-based Pricing 20 Performance Transparency: UnitedHealth Premium Designation Dr. Pratt s Patients Mrs. Jones Claim 1, 2, 3 Ms. Parker Claim 1, 2, 3 Mr. Smith Claim 1, 2, 3 Assess Quality of Care Evidence-based Procedure-related Measures Meets Criteria for Quality Designation Dr. Pratt Receives Quality Designation Eligible for Cost Efficiency Designation Total Resources and Total Costs: Population Costs (applicable specialties) Receives Quality AND Cost Efficiency Designation Compare Resources Used and Costs to the Market Median Episodes of Care Adjusted for: Case-mix and severity of patients to account for differences in practice, patient type and illness burden 21 7

8 Informing the Consumer (and the Physician) Through Transparent Display of Quality & Efficiency 22 Price Transparency: UnitedHealth myhealthcare Cost Estimator Physician and Facility Specific Cost Estimates As of end of 2012, 175 Health Services Preventive Radiology Lab tests Common IP/OP Procedures, e.g. Hernia Repair Cholecystectomy Gastric Bypass Including historical claims and fee schedule rates Assess Quality of Care Displays physician Premium Designation where applicable Incorporates facility designations where available Assess Price by Market Benchmark Compare cost of services and common procedures among providers in a market Evaluate provider cost against market average & benchmarks Understand complete cost by Care Path (episode) Customize for Each Patient Mr. Smith selects provider based on Quality Care AND Out of Pocket Cost Info Out of pocket costs are based on individual benefit plans Provide HSA balances for consumer planning 23 Price Transparency Is Connected to Performance Transparency 24 Choose: Healthcare Cost Estimator - Demos and Promotional Videos 8

9 View360: Prospective Quality Measures for Physicians and Groups Online tool Updated monthly About 50 HEDIS measures Completion to date Gaps for remainder of calendar year Delegation to authorized staff Online reconciliation 25 View360 Online Screenshot 26 Delivery System Transformation Value-based Continuum ncial Risk Level of Finan UHC s modular set of valuebased payment models align with a provider s risk readiness. Bundled/Episode Payments Performance-based Contracts (PBC) Shared Savings Shared Risk Capitation Capitation + PBC Centers of Excellence Performance-based Programs Accountable Care Programs Fee-for-service Degree of Provider Integration 27 9

10 28 Accountable Care Platform Performance Measure Examples Cancer Screening Diabetes Care Coronary Care Hospital Readmission Rates Hospital Average Length of Stay Hospital-Acquired Conditions/Infections Early term Deliveries Quality Measures Potentially Avoidable Hospitalizations/ACSH Appropriate Use Measures Total Costs of Care/Medical-Pharmacy Cost Trend Tier 1 Prescribing In-network PD Referrals Inpatient Admissions from ER Advanced Imaging in ER 1-day Admission Rate Registry Measures Ratio Measures e.g. Spine fusion rate, intraoperative cholangiogram rate 29 Sample Physician-Level Measures Example: GI Physicians/Practice Process measures Hepatitis C: Patients with cirrhosis that had a liver imaging study in the last 12 months Inflammatory Bowel Disease: Adults 40 years and older taking chronic corticosteroids that had osteoporosis screening in the last 24 months Quality measures Procedure-based conditions Rate of re-operation Rate of complications (inpatient) Episodes of care Medical conditions Esophagitis, diverticulosis Episodes of care Procedure-based conditions Cholecystectomy, inguinal hernia repair Screening / surveillance colonoscopy Other measures as for the Accountable Care Platform, including population cost The Role of Registry data Example: AGA Digestive Health Outcomes Registry Provides clinical information to augment claims data Appropriateness of Care: Surveillance colonoscopy interval Outcome measures: Adenoma detection rate, complications Gaps, Opportunities: What s Needed Market imperatives are driving acceleration of both payer and provider transformations Consistency and alignment initiatives, while desirable, tend to operate in lower gear vs. current high-gear pace of payment/delivery reforms Thus consistency and alignment activities need to re-orient to this faster pace, and work from the front, not the back, of the cutting face Need more accelerated work on measures of cost, efficiency, appropriateness, outcomes (including patient-reported) Need to build alignment into the work streams of public and private initiatives vs. current retrofit approach Opportunities: EHRs/Meaningful Use; Registry Movement; Consistent Reporting Strong need to build from the consumer s perspective, not payer or provider 30 10

11 How Physicians Can Demonstrate Value Quality measurement it s not just process anymore! Appropriateness of care Improved quality outcomes Demonstrate Affordability Tier 1 prescribing Site of service Improve process and decrease cost of production = ability to offer same or better service at lower price Time-driven activity based cost accounting Kaplan and Porter High value care ties to performance and price transparency, benefit design, network configuration, and value-based contracting 31 Summary Data and measurement are increasingly important for achieving the Triple Aim and demonstrating value Decide on your goals Pick your measures Outcomes Real costs Strive to improve value = outcomes/cost Data available from payers can be an important source of information Employers and consumers have an interest in performance measurement and are demanding information on quality and cost 32 Our United Culture. Our Foundation Our Mission Is to Help People Live Healthier Lives. Our Role Is to Make Health Care Work for Everyone. Building Partnerships to Unlock the Future of Health Care. 33 Confidential Proprietary Information Property of of UnitedHealth UnitedHealth Group. Group. Do Do not not distribute distribute or reproduce or reproduce without without express express permission permission of UnitedHealth of UnitedHealth Group. Group. 11