Richard E. Ward, MD, MBA VP, Clinical Programs and Medical Informatics. Charles Carpenter Director, Medical Advantage Group

Transcription

1 Richard E. Ward, MD, MBA VP, Clinical Programs and Medical Informatics Charles Carpenter Director, Medical Advantage Group

2 Partnering for Value as Bridge to Future Current State Partnering for Value Next Generation PPO Concept Stronger role for primary care (medical home, not gatekeeper) Providers at some risk (gain-sharing, not capitation) Short- Term Value Quality Improvement, Cost Savings and Market Leadership Enhances Competitiveness Preparations Foundation for Future 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 2

3 BCBSM Value Partnerships PGIP: Physician Group Incentive Program Prof-CQI: Michigan Anticoagulation Quality Improvement Initiative Physicians Prof-CQI: Lean Thinking Clinic Reengineering Consortium 3 CQIs: Collaborative Quality Initiatives Michigan Surgical Quality Collaborative Michigan Bariatric Surgery Collaborative BMC2: BCBSM Cardiovascular Consortium Angioplasty Collaborative Quality Initiative Michigan Society of Thoracic Surgeons Cardiac Surgery Collaborative Quality Initiative Michigan Breast Oncology Quality Initiative Advanced Cardiac Imaging Consortium Hospitals Hospital Incentive Program (in Participating Hospital Agreement) 3

4 PGIP Development & Expansion 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 (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 s=73% 2,086 Spec=27% Members 609,704 1,159,861 1,541,165 1,687,524 1,772,598 Specialties Added Cardiology Immunology Radiology Hospitalists Nephrology Medical Oncology Ob/Gyn Hematology Pulmonology 4

5 PGIP Quarterly Meeting 5

6 Physician Group Incentive Program (PGIP) Organizational Model Primary Care Leadership Committees Medical Oncology Hospitalists 1 Initiatives (Core Teams) Improvement Capacity Initiatives 2 Condition Category Initiatives Interest Groups Ad Hoc Projects 3 Service Category Initiatives Self Management Systems Integration Michigan PGIP Analytic Consortium (MPAC) (hosted by U of Mich) 4 Core Process Investment Initiatives Advanced Medical Home and Planned Care Visits Organizational Functions 5 Provider Improvement Infrastructure Initiatives Academic Detailing/ Regulation Pharmacists 6

7 PGIP Initiatives 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 7of the Patient Centered Medical Home (PC-MH) *Coordination of Care *Preventive Services *Specialist Referral Process *Linkage to Community Services *Self-Management Support

8 Each PO has its own strategy for practice transformation PGIP Initiatives related to Patent-Centered Medical Home Year Launched 8 *(Change between 2008 and 2009)

9 Patient Centered Medical Home PGIP Phys Org B PGIP Phys Org A PC-MH Nominee PC-MH Nominee PC-MH Nominee PC-MH Nominee PC-MH Nominee PC-MH Nominee PGIP Phys Org C Control Group 9

10 Patient Centered Medical Home PGIP Phys Org B PGIP Phys Org A PC-MH PC-MH PC-MH Nominee PC-MH PC-MH Nominee PC-MH Nominee PGIP Phys Org C Control Group 10

11 BCBSM Patient-Centered Medical Home Designation Physician Organizations nominated 44% of their s 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) 11

12 BCBSM Patient-Centered Medical Home Designation BCBSM designated 300 Primary Care Practices 1,200 Physicians, representing 25% of PGIP s) 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 12

13 BCBSM PCMH Designation not Geographically Uniform 13

14 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 14

15 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 15

16 LEAN Process Improvement 16

17 Improving Diabetes Care Process using Lean

18 PGIP Performance on Evidence Based Care Delivery 2005 through 2Q09

19 PGIP Performance on Prescribing Generic Drugs 19 19

20 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 $ $0.87 $

21 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 21

22 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 selfmanagement goal setting for at least 1 chronic condition (e.g., all patients with diabetes) 35% systematically provide action plan development and selfmanagement 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 22

23 BCBSM PCMH-designees have more favorable risk-adjusted utilization and standard cost profiles 23

24 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 24

25 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 patientcentered 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 25

26 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 26

27 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 27

28 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 28

29 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,

30 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 30

31 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, 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 31

32 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. ( 32

33 33 Ref: How to Create Accountable Care Organizations by Harold D. Miller. (

34 Goals of Payment Reform 34 Ref: How to Create Accountable Care Organizations by Harold D. Miller. (

35 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 35

36 Multiple Sources of Revenue for PCMH 36