Pay for Performance: Experiences Within An Integrated Delivery System

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Pay for Performance Experiences Within An
Integrated Delivery System

• Jessica C. Dudley, M.D.
• Chief Medical Officer
• Brigham and Womens Physicians Organization
• jdudley_at_partners.org
• March 4, 2009

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Key points

• P4P Contracts have begun to engage physicians
  around addressing quality and efficiencybut
  there are limitations.
• The intense expansion of medical knowledge and
  technology are major contributors to rising
  costs, but provide us an incredible opportunity
  to diagnose and treat conditions previously
  unrecognized or untreatable.
• The electronic medical record is a critical tool
  in providing physicians with the best available
  information about an individual patient and is
  key to improving efficiency and effectiveness of
  care.
• Data and reporting are essential for measurement
  of performance showing variation vs. ones peers
  is an effective means to engage physicians.
• Care reimbursement models continue to evolve, and
  alternative payment models which support (and
  reward) quality and efficiency of care delivery
  will need to be developed.

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Agenda

• Partners Healthcare System (PHS) and Brigham and
  Womens Physicians Organization (BWPO)
• Pay for performance (P4P)
• Medical management and P4P at PHS and BWPO
• Efficiency Pharmacy example
• Quality Diabetes example
• Process E-Prescribing example
• Future
• CMS PQRI and VBP
• Other

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Partners HealthCare An Integrated Delivery
System
Dana-Farber/ Partners Joint Venture
Partners HealthCare System, Inc.
Two Physicians Appointed by Partners

Partners CommunityHealthCare, Inc.
Brigham And Womens/ Faulkner Hospitals
North Shore Medical Center, Inc.
Newton- Wellesley Health Care System, Inc.
The Massachusetts General Hospital

• Founded in 1994, shortly after the founding of
  Partners.
• PCHI is the provider network for Partners.
• Intentionally given entity status to assure MD
  voice and build trust

Newton- Wellesley Hospital, Inc.
The General Hospital Corporation
The Brigham and Womens Hospital, Inc.
Faulkner Hospital, Inc.
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Eastern Massachusetts PCHI Overview
100 miles
75 miles
PHS Market Share Data Adult IP Admissions 22
(1) PCPs 23 (2)
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• Source Massachusetts Division of Healthcare
  Finance and Policy Ages 0-17 excluded.
• Sources Folios, Partners Corporate Provider
  Master, PCHI

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Network Composition
Partners Community Healthcare, Inc 6,337 Total
MDs
Primary Care 1,162
Specialist 5,175
Community 743
Academic 419
Community 1,879
Academic 3,296
Total 2,622
More tightly aligned
PHS Community Hospital PHOs 1,013
Integrated Practices 233
Affiliated Groups PHOs 1,376
Less tightly aligned
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Components of a Clinically Integrated Network

• 1. Common practice standards and protocols to
  govern treatment.
• Uniform across the network and across contracts
• Developed and/or implemented via collaboration
  among MDs (PCPs and specialists).
• 2. Programs to monitor and control utilization
  and ensure quality.
• Rank and file MDs are aware of programs/goals and
  can articulate organizations approach to
  quality/efficiency.
• 3. Measurable outcomes that demonstrate
  efficiencies.
• Regular evaluation and reporting back to
  MDs/hospitals
• Incentives/remedies to modify practice patterns
  and ensure compliance.
• Meaningful financial incentives/penalties (payer
  or internal)
• Significant investment in infrastructure
• Support development/management of clinical
  programs
• Common electronic medical record

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Components of a Clinically Integrated Network
Common Practice Standards and Protocols
The elements that define a clinically integrated
network are the same elements that will improve
performance and patient care quality
Programs to monitor control utilization and
ensure quality

• Common electronic medical record

Clinically Integrated Network
Measurable outcomes that demonstrate efficiencies
Significant investment in infrastructure

• Incentives remedies to modify practice patterns
  ensure compliance.

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Agenda

• Partners Healthcare System (PHS) and Brigham and
  Womens Physicians Organization (BWPO)
• Pay for performance (P4P)
• Medical management and P4P at PHS and BWPO
• Efficiency Pharmacy example
• Quality Diabetes example
• Process E-Prescribing example
• Future
• CMS PQRI and VBP
• Other

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Evolving Reimbursement and Care Models
Full Capitation
Closed System
Sub-Capitation
Team-Based Care
Case Rates
Disease Management
Evolution of Supporting Systems
PAYMENT METHODOLODY
P4P (Robust)
EMR
P4P (Lite)
Registries
Fee-for-Service
Non-MD Clinicians
Solo MD Practices
Multi-Specialty Group Practices
Integrated Delivery System
Clinic Model
Group Practices
STAGE OF EVOLUTION
Slide used with permission of Thomas H. Lee, MD,
of Partners HealthCare System
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Components Of P4P Programs
Component
Choices

• Payment or withhold needs to be large enough to
  provide incentive to physicians
• Withhold pool can be significant at practice or
  system level but at the provider level the amount
  of money can be very small
• Timing of withhold settlement impacts the link
  between the performance and return

• Efficiency targets goal of lowering costs
• Prescribing generic medication
• Ordering radiology exams that impact clinical
  decisions
• Quality goals goal of improving health outcomes
  
• Targeted diseases (e.g. diabetes, cardiovascular
  disease)
• Process goals goal of changing status quo
  behaviors or instituting new processes to improve
  quality of care
• Electronic prescribing
• Testing targets (e.g. number of eligible patients
  w/ mammogram)

• Data source claims vs. clinical record vs.
  patient reports
• Adjustments severity, socioeconomic status
• Group vs. individual physicians

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Major Target Areas in Partners P4P Contracting
(Phase 1)

• Hospitals
• Hospital use (and type)
• Radiology
• Computer order entry
• JCAHO cardiac quality measures

• Physicians
• Hospital use
• Pharmacy
• Radiology
• Electronic record adoption
• Diabetes/Asthma/ Chlamydia screening

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Slide used with permission of Thomas H. Lee, MD,
of Partners HealthCare System
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Community PCP EMR AdoptionCommunity PCP
EMR Adoption TrendE
Data as of December 31, 2007.
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Slide used with permission of Thomas H. Lee, MD,
of Partners HealthCare System
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New Major Target Areas in Partners P4P
Contracting (Phase 2)

• Hospitals
• Hospital use (and type)
• Radiology
• Safe medication administration systems (e.g.,
  eMAR, smart pumps)
• JCAHO cardiac quality measures
• NSQIP/IHI
• Patient experience of care (HCAHPS)
• End of life care

• Physicians
• Hospital use
• Pharmacy
• Radiology
• Electronic record effective use (electronic
  prescribing, problem list accuracy)
• Diabetes outcomes (LDL, BP, HbA1c)
• Patient experience of care
• End of life care
• Shared decision making
• High risk patient identification and referrals

The contract goals are becoming more meaningful
and that is only possible because of the progress
with EMR and other systems achieved thus far.
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Slide used with permission of Thomas H. Lee, MD,
of Partners HealthCare System
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2009 Summary Of BWPO Physician P4P Programs
Overview
P4P Goal
BWPO Medical Management Program

• Prescribe generics and lower cost brand drugs
  where appropriate
• Order appropriate imaging tests when necessary
  for diagnosis management
• Encourage appropriate site of care for
  individual patients

Efficiency

• Pharmacy
• Radiology
• Inpatient

Quality

• Programs that identify and support physicians in
  management of patients with targeted diseases
• Case Management for patients at risk for
  readmission
• Pharmacy management for targeted patients

• DM
• HTN
• CVD

Process

• E-Prescribing Training
• Advanced directive education
• Distribution of patient education materials

• E-RX
• End of Life
• Shared Decision

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Annual cost differential prescribing a generic
drug can provide a patient (and the system) over
a four fold cost savings to the patient and a ten
fold overall cost savings
Efficiency Pharmacy Example
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Problem What happens when we dont get it right
the first time?
Efficiency Pharmacy Example
Cost Barrier 45 co-pay
Mrs. Jones is a 50 y.o. female. Newly diagnosed
with depression.
No Fill
Rx - Lexapro
Access Barrier Prior Auth Required
Prescribed by Psychiatrist
Rx citalopram 10 copay
Back to PCP
Fill
Goal To influence MDs behavior so they write
right the first time.
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Efficiency Pharmacy Example
BWPO PRIMARY CARE PRESCRIBING POLICY
Pharmacy BWPO Primary Care Prescribing Policy
It is the policy of Brigham and Womens Primary
Care to first prescribe a generic or over the
counter (OTC) drug if available. When there are
no Generic or OTC drugs available, or if there is
a documented generic/OTC failure, physicians will
work with patients to find an appropriate
alternative.
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Efficiency Pharmacy Example
Physician Education Approach Adult Therapeutic
Grid

• Physician Education
• Target a sub-set of most frequently prescribed
  drug classes.
• Clinical review of each class to support
  Therapeutic Effectiveness (PCHI Outpatient Drug
  Management Committee).
• Identify lower cost brand and generic
  alternatives.
• Develop and disseminate PCHI Therapeutic Grid
  with supporting Prescriber and Patient Education.

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Point of Care Optimal Approach achieved through
use of EMR
Efficiency Pharmacy Example

• Support providers at time of prescribing, guiding
  them to most efficient and cost effective Rx for
  specific patient based on their insurance or lack
  thereof.

LMR identifies Nexium as red
PCP enters Rx - Nexium
No Rx
40 y.o. female with dyspepsia
Select from Alternatives
Rx omeprazole
Fill
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Point of Care Supports Efficient Prescribing and
Promotes Quality Care Through Real Time Decision
Support
Efficiency Pharmacy Example
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Point of Care Supports Efficient Prescribing and
Promotes Quality Care Through Real Time Decision
Support
Efficiency Pharmacy Example
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Generic - By PCP (Example Of A Report For One
BWPO Practice)
Efficiency Pharmacy Example

• Average BWPO Generic is 81.76 v. Practice
  average of 78.41
• Patients who pay generic vs brand co-pays save an
  avg. of 420/year
• Studies show that high drug costs adversely
  impact medication adherence

• Pharmacy claims data Jan 08 Jun 08

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BWPO Pharmacy Use Of Generic Drugs Has Steadily
Risen
Efficiency Pharmacy Example
BWPO pharmacy trends, q106-q408 generic
prescriptions written
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Quality Diabetes Example
Opportunities For Improvement In Getting Patients
To Target
of BWPO P4P Patients with diabetes at target
for LDL, A1C, BP, and all three
Source Matrix (CDRClaims) as of 12/5/08 Missing
Data counted as not at target
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Quality Diabetes Example
Quality Variation In LDL Target Achieved By
Practices
Percent of patients with CVE or diabetes at LDL
target
Source Matrix (CDRClaims) as of 12/5/08 LDL
Compliant LDL Drawn in 2008 with value less than
100
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BWPO PCP Action Reports Inform Physicians
about Patients and Offers Provider Support for
Follow-Up
Quality Diabetes Example
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There is no one size fits all solutionbut
using electronic communication with linkage to
EMR improves efficiencies.
Quality Diabetes Example

• Results from the PCP Action Reports
• PCPs Returned the Reports
• Reports alone are not an effective tool for
  enrollment of patients in programs external to
  PCP office
• Only 5 of eligible patients were signed up for
  LDL titration program via report
• Further education on protocol followed by direct
  email outreach with communication of eligible
  patients along with LDL titration protocol to
  PCPs resulted in much higher interest in
  enrollment.
• Preliminary results reveal approx 60 enrollment
  rate
• Next Steps
• List Management Software
• Electronic communication
• Links from the reports directly into the patients
  medical record
• Use electronic survey communication to capture
  physician follow-up orders

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E-prescribing Adoption
Process E-Prescribing

• E-Prescribing improves physician efficiency and
  patient quality
• With favorites it typically only takes a few
  clicks to prescribe and renew prescriptions
• Prescriptions are accurate and clear, no more
  deciphering physician handwriting
• System can provide real time decision support
  system can warn of drug/drug interactions,
  allergies listed in patient record, lower cost
  alternatives
• BWPO developed a program that customized the
  medication module for each practice and trained
  physicians on how to efficiently use the system
• Key elements
• Leadership buy in
• Engage super-user
• Customize medication module set up favorites
  and short cuts
• Customize training presentations, one-on-one

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E-prescribing preset favorites help physicians
quickly prescribe meds they use most often
Process E-Prescribing
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Process E-Prescribing
E-prescribing Real Time Decision Support
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BWPO E-prescribing Performance improving
Process E-Prescribing
Percent of physicians using e-prescribing
2009 Target 75
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Some shortcomings of P4P
Problem
Description

• Focus on achieving process metrics, not always on
  outcomes
• E.g., testing targets focus on getting the test
  done, not the results

• Work to the target and not beyond
• If threshold set too high, some MDs may not see
  hope of payment

• Majority of targets linked to PCP engagement
  very few current goals tied to specialist
  engagement
• Providers at risk for things they cant control
• Poor patient adherence
• Varying severity of illness

• Different payors have their own programs, with
  their own targets
• Not all patients included, but physician practice
  doesnt change by payer
• Often difficult to measure with existing data
  resources

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Agenda

• Partners Healthcare System (PHS) and Brigham and
  Womens Physicians Organization (BWPO)
• Pay for performance (P4P)
• Medical management and P4P at PHS and BWPO
• Efficiency Pharmacy example
• Quality Diabetes example
• Process E-Prescribing example
• Future
• CMS PQRI and VBP
• Other

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CMS PQRI and Value Based Purchasing

• CMS Physician Quality Reporting Initiative
• Current model is bonus for reporting on
  selected quality metrics and demonstration of E
  prescribing
• Physician participants to date have experienced
  many challenges and few have received anticipated
  payments
• Anticipate will become required for payment,
  not bonus going forward
• CMS Issue Paper December 2008 with plans to
  transition from FFS to Value-Based Purchasing
• Acknowledging that fee for service NOT effective
  for ensuring quality and efficiency
• Goal of providing right care for every person
  every time
• Promote practice of evidence based medicine
  (msmt, financial incentives, public reporting)
• Decrease fragmentation and duplication of care
  (episodes of care, smoother transitions)
• Effective management of chronic diseases (focus
  on prevention, preventable admissions, advanced
  care planning, end of life care)
• Accelerate adoption of HIT
• Empower consumers to make value based health care
  choices

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Some Conclusions from P4P

• Take risk on things you can control
• Engage physicians in the process
• Leverage EMR technology
• Creates efficiencies in engaging physicians at
  point of care
• Provides more comprehensive information about
  individual patients
• Deploys clinical decision support
• Captures information for measurement and
  reporting
• Aim for concordance of measures across health
  plans
• Be proactive in designing systems
• Approach may vary by measure
• Understand your organizations strengths and
  weaknesses
• Measuring the impact of a program can be a
  challenge
• Process vs. outcome
• Quality vs. efficiency
• Modify programs as you learn more

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A recap

• P4P Contracts have begun to engage some
  physicians around addressing quality and
  efficiencybut financial risk is minimal and
  affects primarily primary care physicians and not
  specialists.
• The intense expansion of medical knowledge and
  technology and the accompanying rising costs
  demand changes in the traditional models of
  individual providers caring for individual
  patients under a FFS system and support more team
  based care with alternative payment models which
  support quality and efficiency of care delivery.
• The electronic medical record is a critical tool
  in providing physicians with the best available
  information about an individual patient and is
  key to improving efficiency and effectiveness of
  care. Physicians need to adopt the use of EMRs
  and will need to be trained in effective use.
• Data and reporting are essential for measurement
  of performance showing variation vs. ones peers
  is an effective means to engage physicians.
• Patients will need to become more engaged in
  their health care management and decision making
  with increased transparency.