Optimizing Patient Flow Through Physician Care Variation Management

Optimizing Patient Flow Through Physician Care Variation Management Fred Hosler, MD and Larry Burnett, RN May 2012

Discussion Outline Market Forces and Reform Initiatives Dimensions of Care Variation Improvement Assessing Your Organization Implementing Care Variation Improvements Common Improvement Challenges and Related Strategies 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 2

How Does Care Variation Impact Patient Flow? Optimal patient flow is fundamentally the delivery of the right care at the right time in the right setting. 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 3

Market Upheaval and Opportunity The Healthcare Reform Bill and Private Sector trends are having a profound effect on healthcare providers: Immediate reductions in reimbursement to hospitals and physicians Focus on value-based purchasing higher quality and lower costs Financial penalties for poor quality outcomes Transition from volume-driven fee-for-service payments to valuebased purchasing and bundled payments Accountable Care Organizations (ACO s) Private Sector moving independently to control rising cost of healthcare 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 5

Key Health Reform Initiatives Hospital Readmission Data go Public Increased Medicaid Payment for Primary Care Physicians Individual and Business Mandates Dependents Covered to Age 26 Report Healthcare Benefit Value on W-2 Penalties for High Readmission Rates Hospital-Acquired Infections Publicly Reported Exchanges and Affordability Credits Ends Rescissions and Coverage Limits Community Health Center Funding Co-Ops Established Medicaid Expansion 2010 2011 2012 2013 2014 Medicare Market Basket Update Productivity Reductions Begin No Federal Matching for Medicaid Hospital- Acquired Conditions Monitoring for Hospital & Physician Value Based Purchasing Standards Begins Bundled Payment National Voluntary Pilot (5 year agreements) Medicare and Medicaid DSH Cuts Not-for-Profit Requirements Begin Accountable Care Organizations Pilot Providers can Qualify for Incentives VBP Program for Hospital and Physician Payments Independent Payment Advisory Board Source: HFM Magazine, May 2010 Excessive Readmissions for AMI, CHF, PN Result in 1-3% Penalty (all DRGs) Reduced Payment for High Levels of Hospital- Acquired Conditions (1% for worst quartile) 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 6

Hospital Value-Based Purchasing (VBP) Program Centers for Medicare and Medicaid Services (CMS) approach to paying more for high-quality care, and less for low-quality care Medicare will reward hospitals that deliver high-quality care with incentive payments To measure quality, Medicare will use certain process-of-care measures hospitals have already been reporting through the Hospital Inpatient Quality Reporting (IQR) Program, as well as scores from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) To fund these incentive payments, Medicare will reduce the base operating diagnosis-related group (DRG) payments for hospitals discharges in each fiscal year (FY) starting in 2013 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 7

VBP Process-of-Care Measures Example: Acute Myocardial Infarction Measure ID AMI-2 AMI-7a Measure Description Aspirin Prescribed at Discharge Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival AMI-8a Primary PCI Received Within 90 Minutes of Hospital Arrival 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 8

The Market s Focus on Value the U.S. has the highest per capita health care costs of any industrialized nation... Yet as much as 20 to 30 percent of these costs may be unnecessary, or even counterproductive, to improved health. Institute of Medicine. Value in Health Care: Accounting for Cost, Quality, Safety, Outcomes, and Innovation. Workshop Summary. December 16, 2009 In just six categories of waste overtreatment, failures of care coordination, failures in execution of care processes, administrative complexity, pricing failures, and fraud and abuse the sum of the lowest available estimates exceeds 20% of total health care expenditures. The actual total may be far greater Special Communication, Eliminating Waste in US Health Care Donald M. Berwick, Andrew D. Hackbarth, JAMA. 2012; Published online March 14, 2012 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 9

The Market s Focus on Variation and Inappropriate Utilization service use in higher use areas (90 th percentile) is 30% greater than in lower use areas (10 th percentile); the analogous figure for spending is about 55%. Medicare Payment Advisory Commission. Report to the Congress. Regional Variation in Medicare Service Use. January 2011 Excessive testing costs $200 billion to $250 billion (per year).there s an overuse of imaging studies, CT scans for lung disease, overuse of routine electrocardiograms and other cardiac tests such as stress testing. Dr. Steven Weinberger, CEO, American College of Physicians, quoted in Stemming the Tide of Overtreatment in U.S. Healthcare, Reuters. Published online Feb. 16, 2012 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 10

Growing Physician-Led Movement to Identify Over-Utilization Recent example is the Choosing Wisely project, organized by the American Board of Internal Medicine (ABIM) and promoted by Consumer Reports Seventeen professional societies are participating in identifying diagnostic and treatment procedures that are over-utilized and can create more risks than benefits Examples include CT scans for low back pain, antibiotics for sinus attacks, stress cardiac imaging or other advanced noninvasive imaging in asymptomatic patients or those at low risk for coronary disease Some of the participating societies include the American College of Radiology (ACR), the American College of Physicians (ACP), the American Academy of Family Physicians (AAFP), and the American College of Cardiology (ACC) Doctors Say 45 Common Tests 'Overused' John Gever, MedPage Today; Published online April 04, 2012 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 11

National Quality Forum The National Quality Forum (NQF) has endorsed eight measures on healthcare resource use and costs with a focus on diabetes, cardiovascular care, asthma, pneumonia, COPD, hip/knee replacement, and total primary-care costs NQF defines resource use measures as comparable measures of actual dollars or standardized units of resources applied to the care given to a specific population or event, such as a specific diagnosis or procedure These endorsed measures could become incorporated in payor s valuebased incentive reimbursement programs 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 12

NQF s Endorsed Measures 1557: Relative Resource Use for People with Diabetes (National Committee for Quality Assurance) 1558: Relative Resource Use for People with Cardiovascular Conditions (National Committee for Quality Assurance) 1560: Relative Resource Use for People with Asthma (National Committee for Quality Assurance) 1561: Relative Resource Use for People with COPD (National Committee for Quality Assurance) 1598: Total Resource Use Population-based per member per month Index (HealthPartners) 1604: Total Cost of Population-based per member per month Index (HealthPartners) 1609: ETG based hip/knee replacement cost of care (Ingenix) 1611: ETG based pneumonia cost of care (Ingenix) 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 13

TJC s Proposed National Patient Safety Goal (NPSG.16.01.01) NPSG.16.01.01: Minimize the overuse of tests, treatments, and procedures to reduce the risk of patient harm. Rationale: Overuse may be defined as the use of a health service in circumstances where the likelihood of benefit is negligible and, therefore, the patient faces only the risk of harm. Seen from this perspective, overuse is a safety and quality problem. 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 14

TJC s Proposed NPSG.16.01.01: Elements of Performance Element Timing Description 1 2 3 4 5 In effect as of January 1, 2013 In effect as of January 1, 2013 In effect as of January 1, 2014 In effect as of January 1, 2014 In effect as of January 1, 2014 Initiate a program to address tests, treatments, and procedures that, when overused, may result in harm to patients. Evaluate whether overuse is occurring for the selected treatment, procedure, or test, and if it is, how it can be addressed. If the evaluation identifies potential overuse, use performance improvement tools and methods in conjunction with clinical practice guidelines to reduce the inappropriate use of treatments, procedures, and tests. Specific clinical practice guidelines are to be determined. Evaluate the effectiveness of efforts to minimize overuse and take action to improve. Take action when planned improvements are not achieved or sustained. 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 15

Variation Will Never be Eliminated Care delivery is complex; patients often have multiple co-morbidities Cannot, nor would you want to, remove all variability; each patient and care plan is unique Goal should be to manage variation, striving to achieve the highest quality and degree of variation reduction for each patient while delivering care based on evidence-based best practices 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 16

Not All Variation is Inappropriate Not all variation is undesirable or inappropriate. Variation can be appropriate when it is due to the characteristics of the population served (e.g., age or gender) or the varying circumstances of providers (e.g., special missions, costs of doing business, rural/urban location). Other variation is inappropriate, such as when providers fail to adhere to established medical practice resulting in the over, under, or misuse of services Despite this complexity, the task force concluded that a significant portion of variation is under the control or influence of hospitals and other providers, and that the time for action is now. American Hospital Association, Report Of The Task Force On Variation in Health Care Spending January 10, 2011 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 17

Many Industry Stakeholders are Weighing In on Care Variation What s At Stake Hospitals need to pay attention to the dialogue and determine their response Reimbursement: CMS Value-Based Purchasing Program metrics New insurer requirements tied to quality outcomes Accreditation: The Joint Commission s focus on overutilization (NPSG.16.01.01) Consumer Perception: Quality and utilization metrics reported out and publically available Market Position Relative to Competitors: Consumers ability to compare performance across hospitals 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 18

Care Variation Improvement Dimensions Care Variation Improvement Dimensions Comprehensive performance improvement is required to decrease inappropriate utilization and variation among physicians. Technology alone is not sufficient. Processes Interdisciplinary care delivery Care management across the care continuum People Clinician leadership Clinician alignment Effective accountability model including approval, oversight, and monitoring of improvement initiatives Clinical Guidelines Evidence-based clinical guidelines Clinical pathways Clinical research Tools/Technologies Clinical Performance Improvement Systems Point-of-care technology such as EMRs and order entry systems 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 20

Challenges Across the Dimensions Processes Operational structures and processes to deliver care Challenges Process improvement may not get the focus it needs if there is an over-reliance on IT as the silver bullet to ensure care is clinically appropriate and delivered efficiently according to evidence-based standards Process improvement methodologies commonly used to make improvements (lean, Six Sigma, etc.) may not be comprehensive enough to catalyze transformational change People Getting the right people involved at the right time in the right place with the right accountability Challenges The level of performance and quality improvement that now must be accomplished due to external pressures is unprecedented; for many organizations it will take a significant cultural shift to achieve and maintain the level of accountability and discipline needed to achieve variation reduction and patient flow imperatives Driving evidence-based best practices and an optimal level of variation reduction at point-of-care is difficult Lack of effective physician governance and accountability model to monitor implementation of clinical guidelines and assure adoption 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 21

Challenges Across the Dimensions (cont d) Clinical Guidelines Evidence-based clinical guidelines, clinical pathways, and published clinical research Challenges Clinical guidelines are being developed by many groups for many conditions; significant effort is required to track new clinical content and ensure evidence-based approaches stay up to date with the latest clinical research and recommendations Many organizations have pathways or guidelines they have adopted, but they sit in a drawer and are not effectively used to drive clinical decision making and care delivery; they are paper-based and have not been operationalized at point-ofcare Tools/Technologies Clinical information and performance improvement IT systems and point-of-care systems with embedded clinical pathways and guidelines Challenges Effective delivery of evidence-based clinical guidelines and clinical pathways at point-of-care through technology is still evolving Automating pathways and EMR order sets that are adopted in mass and provide a menu of everything a physician may want to order and which can be selected with the click of a button can contribute to over-utilization Over-reliance on the tool to remove variation is common, when what is required is comprehensive reengineering of process, people, and tools to ensure the patient receives the right care at the right time in the right place 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 22

Relationship Between Clinical Guidelines and Tools/Technologies Clinical Performance Improvement Systems Delivery of Clinical Guidelines and Pathways at Point of Care Evidence-Based Clinical Guidelines and Pathways 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 23

Clinical Performance Improvement Systems Definition Systems used to compare a hospital s performance to benchmarks and monitor the impact of clinical performance improvement initiatives Examples of performance metrics include average length of stay (ALOS), resource consumption, and quality metrics such as mortality Important functionality includes risk-adjusted data, substantial benchmark database, extensive breadth of benchmarks, and ability to compare utilization of resources to benchmarks (e.g., number of CT scans) Examples Total Benchmark Solution Thomson Reuters Premier UHC Solucient Advisory Board 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 24

Evidence-Based Clinical Guidelines: Sources National Guideline Clearinghouse (NGC)*: NGC is an initiative of the Agency for Healthcare Research and Quality. NGC s mission is to provide easy access and dissemination of objective, comprehensive clinical practice guidelines to promote their implementation. Professional societies, universities, and other industry organizations; examples: Society of Critical Care Medicine: Sedation Guidelines University of Michigan Health System (UMHS): COPD Guidelines Institute for Healthcare Improvement: Sepsis Protocols Condition-specific coalitions; examples: Global Initiative for Chronic Obstructive Lung Disease (GOLD) Surviving Sepsis Campaign * National Guideline Clearinghouse; 2012.. Available here: http://www.guideline.gov/ 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 26

Example: Sepsis Resuscitation Bundle* IHI s Sepsis Resuscitation Bundle includes the following evidence-based elements that should be implemented together within 6 hours (not all may be required, but the appropriateness of all 7 should be assessed and determined): Serum Lactate Measured Target time: Within minutes If lactate > 4 mmol/l (36 mg/dl), proceed with early goal-directed therapies Blood Cultures Obtained Prior to Antibiotic Administration Collect prior to initiation of broad-spectrum antibiotics (tailored after blood culture results available) Goal=100% Improve Time to Broad-Spectrum Antibiotics ED: 3 hours or less for initiation of broad-spectrum antibiotics to severely septic patients admitted to the ED ICU: 1 hour or less for patients admitted to the ICU Treat Hypotension and/or Elevated Lactate with Fluids In the event of hypotension and/or lactate > 4 mmol/l (36 mg/dl) deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent). Fluid resuscitation should be commenced as early as possible in the course of septic shock (even before intensive care unit admission). Requirements for fluid infusion are not easily determined so that repeated fluid challenges should be performed. * Sepsis Resuscitation Bundle. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012. (Available on www.ihi.org ) 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 27

Example: Sepsis Resuscitation Bundle* (cont d) Apply Vasopressors for Ongoing Hypotension In the event of hypotension and/or lactate > 4 mmol/l (36 mg/dl), apply vasopressors for hypotension not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP) > 65 mm Hg. IHI identifies a number of cautions, Although all the vasopressor agents generally result in an increase in blood pressure, concerns remain in clinical practice about their potentially inappropriate or detrimental use. Maintain Adequate Central Venous Pressure In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate > 4 mmol/l (36 mg/dl) achieve central venous pressure (CVP) of > 8 mm Hg Following the Sepsis Resuscitation Bundle, once lactate is > 4 mmol/l (36 mg/dl), or hypotension has been demonstrated to be refractive to an initial fluid challenge with 20 ml/kg of crystalloid or colloid equivalent, patients should then have their CVP maintained > 8 mm Hg. Maintain Adequate Central Venous Oxygen Saturation In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate > 4 mmol/l (36 mg/dl) achieve central venous oxygen saturation (ScvO2) of > 70 percent. Mixed venous oxygen saturation (SvO2) > 65 percent is an acceptable alternative. * Sepsis Resuscitation Bundle. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012. (Available on www.ihi.org ) 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 28

Example: COPD Clinical Pathway Day 1: Admission and Evaluation Day 2: Stabilization Day 3-4: Discharge* Key Care Interventions Testing** o Pulse Oximetry o Chest x-ray o ECG o ABGs Oxygen therapy Bronchodilator (MDI with a spacer) Corticosteroid (PO Prednisone or Prednisolone) Antibiotics if symptoms indicate bacterial infection (PO preferred) o Increased sputum purulence (change in sputum color) o Increased sputum volume o Increased dyspnea Noninvasive ventilation (if indicated) Testing: o Pulse Oximetry o ABGs if on oxygen (to ensure satisfactory oxygenation without CO2 retention or acidosis) Oxygen therapy (if indicated) Bronchodilator (MDI with a spacer) Corticosteroid (PO Prednisone or Prednisolone) Antibiotics if symptoms indicate bacterial infection (PO preferred) Noninvasive ventilation (if indicated) Testing: o Pulse Oximetry o ABGs (if needed to confirm stability for 12 to 24 hours) Bronchodilator (MDI with a spacer) Corticosteroid (PO Prednisone or Prednisolone) Antibiotics if symptoms indicate bacterial infection Medical Milestones ABGs improving For patients with oxygen saturation 88%, achieve resting and exercise oxygen saturation 90% Patient demonstrates competency in utilizing MDI with a spacer for Bronchodilator Therapy Switch to PO antibiotics if initiated as IV Inhaled beta 2 -agonist therapy is required no more frequently than every 4 hours Patient, if previously ambulatory, is able to walk across room Patient is able to eat and sleep without frequent awakening by dyspnea Patient has been clinically stable for 12 to 24 hours Arterial blood gases have been stable for 12 to 24 hours 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 29

Point-of-Care Delivery Many systems vendors are working on delivering clinical guidelines at point of care, but the ability to do this effectively is still evolving. Electronic Medical Records (EMRs): Include functionality such as electronic MAR, clinical documentation, order entry, etc. Examples: Epic and Allscripts Vendors are embedding clinical content (e.g., pathways, order sets, alerts) in their systems and attempting to serve as a source for continuously reviewed and updated evidence-based content Comprehensive Hospital Information Systems (HIS) Typically include EMR functionality plus departmental modules such as Pharmacy and Radiology Examples: Cerner, McKesson, Siemens HIS vendors are generally not as strong as the EMR vendors in embedding clinical content 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 30

Typical Care Variation Improvement Opportunities Clinic Hospital Long-Term Home/ Community Access Care Delivery Transition Transparent House Status Pre-Admission Services Centralized Placement Inpatient Perioperative Emergency Care Standards Interdisciplinary Coordination Patient/Family Involvement Coordinate w/ Post-Acute Care Setting Bed Turnaround Level of Care Assessment Escalation Procedures Level of Care/Patient Status Resource Optimization Discharge Preparation Link to PCP/Medical Home Transportation admit discharge Unnecessary inpatient stays Admissions through the ED vs. Direct Admissions Pre-procedure tests, evaluations, and treatments that should be performed outpatient are performed inpatient Opportunity for improved use of consults to ensure patient is aligned with the right clinical programs (e.g. palliative care, pain management, enterostomal) Unnecessary testing, therapies, and medications (e.g., unnecessary daily lab batteries, unnecessary blood administration) Tests performed in inpatient setting that could be performed outpatient (labs, CTs, MRIs, Mammograms, non-emergent tests) Inefficient evaluation of rule-out DRGs (e.g., chest pain, syncope); no timely discharge of low-risk patients with follow-up testing performed in the outpatient setting Treatment inefficiencies (e.g., no physical therapy available on weekends, etc.) Duplicative scope of practice issues services provided by Ancillary departments that Nursing can appropriately provide Inappropriate use of level of care (e.g., inappropriate use of ICU) Lack of evidence-based standards of care Lack of availability of appropriate post-acute care (e.g., inadequate availability of hospice care) Inadequate connection back to primary care provider/medical home 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 32

Care Variation Improvement Indicators Are any of the typical care variation improvement opportunities present in your organization? Is there significant variation in the practice patterns of your physicians? Is your organization performing at less than the 75th percentile compared to national benchmarks? (Keep in mind today s 75th percentile is likely tomorrow s 50th percentile.) Does your organization require a dramatic and sustained improvement in operating margin? Are your organization s publically-reported performance/quality indicators where they need to be for the transparency demanded in today s marketplace? Is your organization ready to meet emerging regulatory requirements related to reducing inappropriate utilization? 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 33

Implementing Care Variation Improvements Compare Current Practice Patterns to Benchmarks and Evidence-Based Guidelines Identify Improvement Opportunities Implement Evidence-Based Standards of Care Measure and Sustain Improvements 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 34

Common Improvement Challenges and Related Strategies Coordinating the Breadth of Change Required for Success Ensure involvement of the appropriate clinical staff Ensure improvement initiatives reflect a comprehensive view of care delivery for target conditions, not a departmental perspective Engaging Medical Staff/Physicians Use a collaborative process that engages and aligns all key stakeholder groups including Physicians Develop a coordinated strategy for addressing Physician-related constraints that may hinder success Develop strong Physician relationships that will support change Support existing Physician governance and accountability model to reinforce and sustain change Ensuring Organization-wide Support and Buy-in Provide visible and strong Senior Leadership support Identify change agents and champions early on and ensure they are involved and engaged in the process Develop and execute a comprehensive communication plan incorporating all stakeholders 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 35

Summary What s At Stake Reimbursement: CMS Value-Based Purchasing Program metrics New insurer requirements tied to quality outcomes Accreditation: The Joint Commission s focus on overutilization (NPSG.16.01.01) Consumer Perception: Quality and utilization metrics reported out and publically available Market Position Relative to Competitors: Consumers ability to compare performance across hospitals Your Organization s Strengths and Weaknesses Performance on CMS metrics? What payors in your market are implementing pay-for-quality programs, and what metrics will they be using? Plans to address the proposed National Patient Safety Goal? How do consumers perceive your organization in terms of quality and efficiency? Proactive plan to address? How do you compare to competitors on publically available quality metrics? Proactive plan to address? Care Variation Improvement Dimensions Processes Interdisciplinary care delivery Care management across the care continuum People Clinician leadership Clinician alignment Effective accountability model including approval, oversight, and monitoring of improvement initiatives Clinical Guidelines Evidence-based clinical guidelines Clinical pathways Clinical research Tools/Technologies Clinical Performance Improvement Systems Point-of-care technology such as EMRs and order entry systems 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 36

For further information please contact: Fred Hosler, MD Senior Director Huron Healthcare fhosler@huronconsultinggroup.com Larry Burnett, RN Managing Director Huron Healthcare lburnett@huronconsultinggroup.com 2012 Huron Consulting Group. All rights reserved. Proprietary & Confidential. 37