Title: Special Legislative Council on Performance-Based Disease Management Programs Chronic Care Management
1Special Legislative Council on Performance-Based
Disease Management Programs Chronic Care
Management
- Marilyn A. Follen, RN, MSN
- Administrator Quality Improvement and Care
Management - Marshfield Clinic
- July 24, 2008
2Objectives
- Review the current realities.
- Definitions
- Review the CMS Physician Group Practice (PGP)
Demonstration Project - Value driven interventions
- Care management initiatives
3Marshfield Clinic
- Over 40 centers throughout northern, central and
western Wisconsin - 750 physicians in 80 medical specialties and
subspecialties - 361,436 patients served
- Patients seen from every county in WI, every
state in the nation, as well as 25 foreign
countries
4Marshfield Clinic
- Mission to serve patients through accessible
high quality health care, research, and
education. - Long term strategy built around the six aims of
the Institute of Medicine that care should be - Safe
- Effective
- Patient centered
- Timely
- Efficient
- Equitable
5Institute of Medicine Crossing the Quality
Chasm
- Current care systems cannot do the job.
- Trying harder will not work.
- Changing care systems is the answer.
6Current Situation
- gt 100 million Americans have more than one
chronic illness. - gt 50 of patients dont get appropriate evidence
based care Rand Corporation. - Best practices could avoid 41million sick days
and gt11 billion in lost productivity. - Patients and family are increasingly recognizing
defects in their care.
2004 Wagner
7Medicare Beneficiaries
- Chronically ill consume gt 95 of Medicare
dollars. - gt 75 have 4 chronic illnesses.
- The group with 4 chronic illnesses consumes
2/3rds of Medicare dollars. - Can no longer think in individual disease state
management strategies given increasing numbers of
patients with multiple chronic illnesses. - Congressional Budget Office Study
8Current System Characteristics
- Fee-for-service
- Regardless of service value
- Disproportionately pays for the wrong things.
- Geographically adjusted
9Centers for Medicare Medicaid Services
(CMS)Physician Group Practice (PGP) Demonstration
- The first value-based purchasing demonstration
applied to providers.
10CMS Physician Group Practice Demonstration
- Medicares first pay-for-performance
demonstration for physicians - Tests physician groups ability to lower costs
and improve quality in traditional Medicare
program - 10 multispecialty physician groups with 215,000
Medicare beneficiaries selected competitively - Provides financial and quality-based payment
incentives - 4-year period beginning April 1, 2005
11Why enter the CMS PGP Project?
- Consistent with the Clinics mission
- Marshfield Clinics long term strategy built
around the six aims of the Institute of Medicine. - Marshfield Clinic was headed in the direction of
value based health care which is consistent with
the CMS PGP demonstration project. - ALL interventions for the CMS PGP demo are
applied to ALL Marshfield Clinic patients.
12One of Ten in the Nation
- Dartmouth-Hitchcock Clinic Hanover, NH
- Deaconess Billings Clinic- Billings, MT
- Forsyth Medical Group Winston-Salem, NC
- Geisinger Clinic Danville, PA
- Integrated Resources for Middlesex Area
Middletown, CT - Marshfield Clinic Marshfield, WI
- Park Nicollet Health Services St. Louis, MN
- St. Johns Health System Springfield, MO
- The Everett Clinic Everett, WA
- University of Michigan Faculty Group Practice
Ann Arbor, MI
13PGP Objectives
- Align reimbursement with quality.
- Promotes using utilization and clinical data for
improving quality. - Encourage coordination of Part A (hospital) and B
(outpatient) services. - Promote efficiency in administrative structures
and care processes. - Reward for improving health outcomes.
14Process Outcome Measures
Blue process measures
15Medicare Physician Group Practice Demonstration
Project
CMS wants to avoid this!
We nt to avoid this situation
16Bottom Lines.
- Improving quality without improving efficiency
results in () - Improving efficiency without improving quality
results in - Our challenge is to improve quality and
efficiency, simultaneously
and fast.
17Marshfield Clinic Strategies
- Leverage Informatics
- Process Improvement Re-design
- Care Management
- Provider feedback
- Focus on Value
18Chartless Environment completed in 2007
19Marshfield Clinic Patient Informatics
- Electronic medical record (chartless in 2007)
- i (intervention) List Planned chronic illness
care - Dashboard diagnoses, medications, appointments,
PreServ at a glance - PreServ - preventive services needed by an
individual
20Example of Chart Note for comprehensive DFE
- EXTREMITIES Without cyanosis, clubbing or edema.
Pedal pulses present. Complete diabetic foot exam
is performed. Dorsalis pedis and posterior tibial
pulses are palpable. Skin and hair distribution
are normal. Sensation is present at all 10 points
on both feet.
21Work Directly With Each Department to
- Standardize care to best practice.
- Best Practice
- Safe
- Effective
- Patient-centered
- Timely
- Efficient
- Equitable
- Quality Improvement Care Management
- Systems Processes
- Clinic Operations
22How did we intervene for the PGP project?
- Multiple simultaneous interventions
- Best practice models developed for core
conditions - Computer based CME opportunities
- Care management programs
- Population based feedback to providers
- Physician/Clinical Nurse Specialist regional
teams
23HTN Best Practice Model (BPM)
- Even the clinical practice playing field.
- Test a reasonable practice model that fills in
where evidence gaps exist. - Provide specifications toward which Departments
manage clinical practice.
24Care Management
- Case management individual patients
- Care management populations of patients
- Blended Specific guideline driven protocols
individualized for a patient - Nurse Line (Triage)
- Anticoagulation Services
- Dyslipidemia Services
25Care Management Initiatives
- Nurse Line (Triage)
- Extension of providers practice
- Seamless access to care 24/7/365
- Guideline driven
- Standing orders
- Adult and pediatric triage guidelines are
developed and reviewed by content experts with
system-wide input from providers and nurses - Support 335 primary care physicians system-wide
- Competency based staff training
- 6 week orientation program
- Test competence
- Extensive QI
- On-going feedback and education
26Care Management Initiatives
- Anticoagulation Care Management
- System-wide program
- 6,500 patients
- Staffed by RNs - work under common set of
physician approved protocols - 8 week orientation program
- Test for competence
- On-going feedback and education
- 6 week on-line certification course through
Southern Indiana University
27Care Management Initiatives
- Anticoagulation Care Management
- Evidenced-based protocols
- Protocols are reviewed at minimum on an annual
basis - Care coordination
- Database
- Data housed in Data Warehouse
- Formal monitoring of metrics and outcomes
- AHRQ study revealed higher levels of
anticoagulant control and fewer hospitalizations
than the control group
28Anticoagulation An Example of Better, Less
Expensive Care Made Cost-Prohibitive by Current
Reimbursement Policy
29Anticoagulation An Example of Better, Less
Expensive Care Made Cost-Prohibitive by Current
Reimbursement Policy
- 5,000 patients/year on warfarin
- Medicare Savings 11.67 million
- Patient Savings 2.5 million
- Marshfield Clinic Costs (1.4 million)
- Reimbursement 0.00
30Care Management Initiatives
- Dyslipidemia
- Telephonic
- Medication management
- Educational focus
- Care coordination
31 Lessons
- Adaptive change is challenging
- Cannot be mandated
- Occurs when care is delivered in a
patient-centric manner with sound clinical
underpinnings - Provider trust and confidence builds with each
new care management program - Outcome data is essential
- Clinical outcome data
- Patient satisfaction data
- Provider satisfaction data
32Results
33(No Transcript)
34Marshfield Clinic PY1 Results
- Marshfield Clinic
- Saved the CMS trust fund 6.02 million net of
the 2 corridor (12 million if 2 corridor
included). - Improved quality measures from baseline
measurement year. - Met 9 of 10 quality measures.
- Earned a performance bonus of 4.5 million dollars
35Challenges
- For patients, purchasers, and providers in the
future -
There will be a need to measure quality to prove
it is high while working to continually improve
quality and work to control costs to maximize
value in the marketplace.
36Challenges
- Competing definitions of quality from multiple
payors - Current reimbursement models do not support
- Practice redesign
- Care management efforts individual or
population based - Convincing payors to engage in sharing of cost
savings for currently non-reimbursed services
(nurse line, anticoagulation, etc).