Bridges To Excellence Rewarding Quality Accelerating IT Adoption in Healthcare

1
Bridges To ExcellenceRewarding
QualityAccelerating IT Adoption in Healthcare
HIT Summit West San Francisco, CA March 8, 2005

• Jeff Hanson, MPH
• Regional Healthcare Manager, Verizon
  Communications
• Board President, Bridges to Excellence

2
AGENDA

• Quality Imperative Employers View
• Program Structure
• Results
• Consumer Engagement
• Lessons Learned

3
Employer Perspective Change is Necessary

• Compelling Stats
• 280,000 people will get the wrong advice today in
  a doctors office
• 2,800 people will be harmed today by a medication
  error
• Equivalent of 390 fully-loaded 747s will die
  this year in the hospital from a preventable
  medical mistake gt1 747/day
• Many of these will be our employees

4
What Problems are we Trying to Solve?

• Big Gap Between What we Know and What We Do
• American adults, on average, receive the
  healthcare recommended for their conditions only
  54.9 of the time
• Nearly one-third of patients with congestive
  heart failure are discharged from the hospital
  without being given ACE inhibitors, even though
  its been known for a decade that these drugs
  provide life-saving benefits
• Translation of medical research into practice is
  slowaverage of 17 years

5
Quality Missing the Mark
Source NEJM 2003 3482635-45
6
Employer Perspective Potential for Cost Savings
Time to change focus without losing sight of
reality
7
Employer Perspective Improved Effectiveness
Leads to Cost Savings
Greater Effectiveness
Healthier Patients
Cost Savings
Incentives
Preventive Screening Disease Management Clinical
Information Systems
Fewer Complications Fewer Medical Errors
Reduced Health Care Costs Increased Productivity
8
WASHINGTON - The Bridges to Excellence (BTE)
coalition, a group of large employers that
collectively support various physician
pay-for-performance efforts around the country,
today announced its largest bonus payout to date
more than 800,000 to 35 medical groups in the
Boston area. The incentive payments reward
physician practices that have implemented systems
and which leverage available information
technology to track and educate patients,
maintain medical records, prescribe medicines and
ensure appropriate follow up. Such systems have
been shown to dramatically improve patient care
and prevent mistakes. December 3, 2004
9
BTE What is Bridges To Excellence?

• Multi-stakeholder approach to creating
  incentives for quality
• Employers, health plans, consumers, physicians
  and group practices
• Mission
• Improve quality of care through rewards and
  incentives that
• encourage providers to deliver optimal care, and
• encourage patients to seek evidence-based care
  and self-manage their conditions
• Focus
• Re-engineer office practices by adopting better
  systems of care
• Demonstrate the reengineering is working through
  better outcomes for patients with chronic
  conditions, starting with diabetes and
  cardio-vascular diseases
• Program costs paid by participating employers

10
BTE Rewarding Outpatient Care

• Bridges to Excellence is a program designed to
  create significant leaps in the quality of care
  by recognizing and rewarding health care
  providers who demonstrate that they have
  implemented comprehensive solutions in the
  management of patients and deliver safe, timely,
  effective, efficient, equitable and
  patient-centered care.
• Quality is measured uniformly using nationally
  accepted standards, collected by an independent
  third party NCQA
• Quality measures are focused on actuarially sound
  performance criteria that provide an opportunity
  for a positive ROI for payers in a
  fee-for-service environment

What were after is a significant reengineering
in the processes of care.
11
BTE Overall Concept

• Employers Commit
• Within Market
• Collaboration
• Critical Mass

• Health Plans
• Supply Data
• Patient Counts per Physician

• Physicians
• Notified
• Reward Potential
• Next Steps

• Practices
• Apply
• NCQA Web site
• Application Fees

• Practices
• Recognized
• NCQA
• 3-yr

• Practices
• Rewarded
• Rewards Based on Patient Counts
• Fees Reimbursed

12
BTE uses nationally recognized physician
recognition programs
Structure (PPC)

• Patient safety e-prescribing
• Guideline-driven care EHRs
• Focus on high-cost patients Care coordination
• Improved compliance Patient education support

Process Outcomes (DPRP HSRP)

• HbA1Cs tested and controlled
• LDLs tested and controlled
• BP tested and controlled
• Eye, Foot and Urine exams

• LDLs tested and controlled
• BP tested and controlled
• Use of aspirin
• Smoking cessation advice

13
The process for recognition and rewards is
straightforward

• Physicians apply for recognition with NCQA
• NCQA send notify of physician being recognized to
  Medstat

• Medstat looks up physician/patient attribution by
  BTE Participant Invoices for rewards
• BTE Participant pays reward to Medstat

• Medstat bundles Participant payments and pays
  physician

14
PPC HIT Adoption

• PPC identifies and highlights doctors and
  medical groups that use information and systems
  to make patient care better. Patient registries,
  online prescribing and electronic medical records
  are among the many processes that may qualify for
  recognition and, in some cases, rewards.

15
We have three programs that are operational now
NCQA Measure set Physician Activation Consumer Activation
Physician Office Link (POL) Physician Practice Connections (PPC) Up to 50 pmpy Physician-level report card, and patient experience of care survey
Diabetes Care Link (DCL) Diabetes Provider Recognition Program (DPRP) Up to 100 pdppy Diabetes care management tool, and rewards for care compliance
Cardiac Care Link (CCL) Heart Stroke Recognition Program (HSRP) Up to 160 pcppy Cardiac care management tool, and rewards for care compliance
16
Summary of Performance Measures
Physician Office Link (PPC) Measures
Clinical Information Systems Patient Education and Support Care Management
Use of Patient Registries Educational Resources (languages) Care of Chronic Conditions (disease management)
Electronic RX and Test ordering systems Referrals for Risk Factors Chronic Conditions Preventable Admissions
Electronic Medical Records Quality Measurement and Improvement Care of High-Risk Medical Conditions (care management)
Diabetes Care Link Measures Req. of Patients Achieving Measure
Tested HbA1c 93
Proportion HbA1c lt 7 40
Proportion HbA1c gt 9.0 ? 20
Eye exams 60
Foot Exam 80
Blood Pressure Frequency 97
Proportion lt 140/90 mm Hg 65
Nephropathy Assessments 80
Lipid Profiles 85
LDL lt130 mg/dl 63
LDL lt100 mg/dl 36
Smoking Status/Cessation Cnsl. 80
Req. of Patients Achieving Measure
Cardiac Care Link Measures
80
Blood Pressure Testing in last 12 mos
75
Proportion lt 140/90 mm Hg
50
LDL lt100 mg/dl
80
Lipid Profiles Done in last 12 mos
80
Patients with aspirin or other antithrombotics use
80
Smoking status cessation advice
17
BTE Incentives
Offices meeting Passing Score in Offices meeting Passing Score in POL POL POL DCL/CCL
Offices meeting Passing Score in Offices meeting Passing Score in Clinical Information System Patient Education Support Care Management DCL/CCL
Any Module Y1 50 50 50 20 of bonus is withheld until practice meets DCL and/or CCL (depends on whether attribution ids diabetics and/or cardiac patients) Doc gets full POL bonus plus extra 80 for each diabetic and cardiac patient when meeting CCL/DCL
Any Module Y2 20 20 20 20 of bonus is withheld until practice meets DCL and/or CCL (depends on whether attribution ids diabetics and/or cardiac patients) Doc gets full POL bonus plus extra 80 for each diabetic and cardiac patient when meeting CCL/DCL
Any Module Y3 10 10 10 20 of bonus is withheld until practice meets DCL and/or CCL (depends on whether attribution ids diabetics and/or cardiac patients) Doc gets full POL bonus plus extra 80 for each diabetic and cardiac patient when meeting CCL/DCL
Two out of three Modules Y1 50 50 50 20 of bonus is withheld until practice meets DCL and/or CCL (depends on whether attribution ids diabetics and/or cardiac patients) Doc gets full POL bonus plus extra 80 for each diabetic and cardiac patient when meeting CCL/DCL
Two out of three Modules Y2 50 50 50 20 of bonus is withheld until practice meets DCL and/or CCL (depends on whether attribution ids diabetics and/or cardiac patients) Doc gets full POL bonus plus extra 80 for each diabetic and cardiac patient when meeting CCL/DCL
Two out of three Modules Y3 30 30 30 20 of bonus is withheld until practice meets DCL and/or CCL (depends on whether attribution ids diabetics and/or cardiac patients) Doc gets full POL bonus plus extra 80 for each diabetic and cardiac patient when meeting CCL/DCL
All three Modules Y1 50 50 50 20 of bonus is withheld until practice meets DCL and/or CCL (depends on whether attribution ids diabetics and/or cardiac patients) Doc gets full POL bonus plus extra 80 for each diabetic and cardiac patient when meeting CCL/DCL
All three Modules Y2 50 50 50 20 of bonus is withheld until practice meets DCL and/or CCL (depends on whether attribution ids diabetics and/or cardiac patients) Doc gets full POL bonus plus extra 80 for each diabetic and cardiac patient when meeting CCL/DCL
All three Modules Y3 50 50 50 20 of bonus is withheld until practice meets DCL and/or CCL (depends on whether attribution ids diabetics and/or cardiac patients) Doc gets full POL bonus plus extra 80 for each diabetic and cardiac patient when meeting CCL/DCL
A top scoring practice can earn up to 20K per
doc/year
18
The rewards are designed to encourage adoption
AND use of better systems

• 3 PCP Practice with 1000 patients covered by the
  program
• 3.5 are diabetic patients
• 2.5 are cardiac patients
• Practice receives total of 54,800
• 40 1000 40,000 for meeting PPC measures
  (POL)
• 80 60 10 1000 14,800 for meeting DPRP
  HSRP measures (DCL CCL)
• Purchaser saves a total of 55,000 less program
  costs (6 pmpy)

19
BTE is live in four markets
Cincinnati, OH /Louisville, KY Boston, MA Albany /Schenectady, NY
Launch Date June 2003 February 2004 May 2004
Program(s) DCL DCL, POL POL, DCL, CCL
of Employers 7 GE, Ford, UPS, PG, Humana, CCHMC, City of Cinci 3 (6) GE, Raytheon, Verizon, (IBM, AZ) 4 GE, Hannaford Bros, Verizon, Golub
of Plans 6 Humana, Aetna, UHC, Anthem, BCBS (OH, AL) 5 Tufts, Harvard, UHC, BCBS(MA, AL), 3 MVP, CDPHP, UHC
of Covered Lives 200,000(7,000 Diabetes) 85,000(3,500 Diabetes) 45,000(2,000 Diabetes 1,000 Cardiac)
20
Weve made great progress in all our pilot
markets already
Jan 2004 Jan 2005
Recognized Physicians PPC 30 475
Recognized Physicians DPRP 60 361
Employees going to recognized Physicians Employees going to recognized Physicians DPRP 1,742
Employees going to recognized Physicians Employees going to recognized Physicians PPC 8,872
Rewards paid to-date Rewards paid to-date 1.07M
Available Rewards Available Rewards 8MM
21
Results to Date
22
Were continuing a rigorous evaluation, but weve
learned a lot

• What we know
• DPRP docs are more efficient, by 15 when
  looking at diabetes costs alone, by 5 when
  looking at overall costs
• What we dont know
• Are POL docs more efficient? Were getting the
  answer from two sources
• Ingenix working with Tufts
• CFP since they have aggregated data in MA
• Are DPRP docs more efficient over time? Were
  also getting the answer from two sources
• Ingenix CFP

23
And they also have lower costs of care, whether
episodes or total costs
24
Why BTE Employer Perspective

• Financial
• DPRP savings est. 15 or 1,000 pppy (medical
  only)
• ROI gt10 members see DPRP doctors
• Verizon est. 50,000 diabetic members
• 5,000 x 1000 5M annual savings (breakeven)
• If 50 DPRP, savings 25M annually (medical
  only)
• If 100 DPRP, savings 50M annually (medical
  only)
• Quality
• Quality does not mean higher cost
• Realign provider incentives
• HIT adoption implications beyond diabetes

25
Rewarding Active Consumers CareRewards

• Four-step process
• Create a profile to establish baseline
• Use CareGuide with doctor to set long term goals
• Use CareJournal to track progress
• Earn CareRewards by answering the self-care
  questions

Employer specific content

• Links to
• MD search to find recognized MDs
• Leapfrog Website for hospital safety data
• Newsletters, news, clinical trials and additional
  health info

Bridges To Excellence, Proprietary Confidential
26
Earning and Redeeming Points
Rewards Customizable by Employer
Bridges To Excellence, Proprietary Confidential
27
Consumers are also engaged through our physician
report card web site

• High-level roll-up of physicians overall
  performance
• Distinguishes relative performance of physicians
  within each level

Bridges To Excellence, Proprietary Confidential
28
Effectiveness results come from NCQA, patient
experience of care from employees
Bridges To Excellence, Proprietary Confidential
29
Lessons Learned/Challenges/Opportunities

• Provider report cards are disliked by almost all
  providers
• BTEs stance has been to tie incentives to public
  disclosure of performance measures using tested
  tools
• Providers are emphatic that patient incentives be
  aligned with provider incentives
• Having the Diabetes/Cardiac Care Rewards program
  has been a significant contribution to the
  positive feedback by providers regarding BTE
• Employer communications to employees and other
  covered members is critical to success of
  initiatives
• But employers need plug play toolkits to
  implement the campaigns
• Engaging consumers adds complexity to an already
  complex program
• Need to source vendors, create specs and test
  consumer tools in addition to setting up all
  processes and operations on provider performance
  measures and rewards

30
Key lessons learned are applied to all markets to
improve performance

• Moving docs to reengineer faces numerous barriers
  cost, privacy, interoperability all
  surmountable
• Physician certification process is resource
  intensive
• Getting multiple purchasers to coordinate
  activities is tough, especially when they are
  used to plans doing everything for them
• You have to be nimble and quick to adapt to
  succeed in changing the market

31
Program Success Factors

• Critical mass re employer participation (covered
  lives) in specific markets
• Active employer and health plan participation in
  each market
• Prompt execution of data agreements
• Buy-in by physician community

Bridges To Excellence, Proprietary Confidential
32
There are 13 additional markets that have
actively expressed interest in BTE

• 4 UHC markets
• 2 Employer specific
• 3 BCBS Plans
• Remainder Coalition based

BTE Markets BTE Interest
33
Market expansion strategic alliances

• Plan Licensing
• BTE UHG initially 10 markets including Omaha,
  South Central Florida, St. Louis
• CareFirst BCBS rolling out POL 1/18/2005
• CMS
• MCMP demonstration program set to be launched,
  with first cooperative market being MA
• Leapfrog
• BTE Leapfrog can cooperate to help regional
  coalitions implement the new Leapfrog Hospital
  Rewards Program
• NBCH
• Currently four coalition members ready to start
  one or more BTE programs

34
We need to add critical clinical areas every year
to get to the bulk of our spend
2005 2006 2007
Inpatient (Leapfrog) CABG, AMI, PCI, Pneu, Delivery Ortho, GI Oncology
Outpatient (BTE) Diabetes, cardiac Internal Med (incl Gyn, Ped), Ortho Oncology
of Total Commercial Spend 25 45 60
35
Were going to continue building programs to
cover most specialties

• 2007

• 2006

• 2005

PPC version 2.0
All Docs
Patient Experience of Care
PCPs (IM, FP, Gyn, Ped, etc.)
PCP Recognition Program
Endo
DPRP
Cardio Neuro
HSRP
Ortho Rheum
MSK RP
Oncologists
Cancer RP
36
BTE Summary

• Focused on physician care reengineering
• Processes of care that are assessed include
  health information technology (i.e. fully
  functional interoperable EHR), patient
  education and care management
• Program launched and operated in four markets.
  Health information technology being rewarded now
  in two markets (MA NY)
• NCQA assesses if practices meet the BTE
  criteria through the PPC program, which is being
  revised into Version 2.0, adding in MCMP
  requirements

Bridges To Excellence, Proprietary Confidential
37
Resources

• Bridges to Excellence.
• www.bridgestoexcellence.org
• National Committee for Quality Assurance.
• www.ncqa.org
• The MEDSTAT Group.
• bridgestoexcellence_at_medstat.com
• Web MD.www.webmdhealth.com
• National Business Coalition on Health
• www.nbch.org