Re-engineering Healthcare Delivery

Re-engineering Healthcare Delivery   Hill‟s Innovations in IT and Clinical Programs  Hill‟s Pay for Performance Program IHA‟s California Pay for Performance Initiative Steve McDermott, CEO Hill Physicians Medical Group Blue Cross Blue Shield Conference September 20, 2006 G:\CorpSvc\APowerpnt\SM\Ed ONEIL 4BC BS 092006 Hill Physicians Medical Group California’s Largest IPA  2,600 physicians/34 affiliated hospitals  380,000 HMO members  Delegated care via seven HMO plans  Serving 9 northern California counties G:\CorpSvc\APowerpnt\SM\Ed ONEIL 4BC BS 092006 2005 Financial Results  Revenue: $414.4 million; 100% HMO capitation  $25.6 million in Pay for Performance bonuses distributed to providers  Net Income: $7.8 million  $26 million retained earnings to fund EMR, IT initiatives; no debt G:\CorpSvc\APowerpnt\SM\Ed ONEIL 4BC BS 092006 PriMed      MSO created in 1981, organized Hill in 1984 Exclusive manager; 430 employees Cost plus performance bonus (9.8%) Ownership Hill/CHW/Management Named to “Top 100 Places to Work” in the San Francisco Bay Area in 2005 G:\CorpSvc\APowerpnt\SM\Ed ONEIL 4BC BS 092006 Leveraging Technology   Relay Health - offers Web-based secure messaging platform that facilitates online medical services for patients and doctors - 900 physicians and 28,000 members registered to use in 2005 Hill inSite – online platform to verify patient eligibility, submit authorizations, check claims status and receive electronic funds transfers - Over 1200 active practices G:\CorpSvc\APowerpnt\SM\Ed ONEIL 4BC BS 092006 Other Online Services        eScript (118,000 online prescriptions, 2005) Referrals to specialists (59,000 in 2005) Secure messages between providers and patients (282,000 in 2005) Lab results transmitted to patients Appointment requests made online 74% of all claims sent to Hill online 34% of authorization requests received online G:\CorpSvc\APowerpnt\SM\Ed ONEIL 4BC BS 092006 Electronic Medical Records       Contract with NextGen to offer an EMR solution Three pilot sites completed in 2005; system-wide rollout over the next five years Consolidates all patient records across all sources of care into a single, accessible database Clinical data repository; data mining “Best practice” protocols Three to five-year effort G:\CorpSvc\APowerpnt\SM\Ed ONEIL 4BC BS 092006 Ten Key Initiatives      Predictive Modeling Group Appointments Polypharmacy Program Neurobehavioral Pain „Clinical Snap-shots‟      „Finding Balance‟ Point of service surveys Practice „Value Grid‟ „Practice Support‟ Leadership Training G:\CorpSvc\APowerpnt\SM\Ed ONEIL 4BC BS 092006 Predictive Modeling     Program that analyzes patient diagnostic, and lab & pharmacy data Identifies patients with highest probability of developing complex, chronic conditions Determined that approximately 28% of patient base at moderate or higher risk for developing or exacerbating chronic conditions Physicians use data to better allocate time to patients with greatest needs, intervening before further complications develop. G:\CorpSvc\APowerpnt\SM\Ed ONEIL 4BC BS 092006 Group Visits Primarily used for diabetics; also for asthma, migraines and other chronic diseases  Patients improved A1C control, more readily incorporate recommended exercise and dietary plans into their lives, fewer ER visits/hospital admissions  G:\CorpSvc\APowerpnt\SM\Ed ONEIL 4BC BS 092006 Polypharmacy Program Pilot Reviewing patients who regularly take 10 or more prescription medications  Identifying adverse reactions to combinations of drugs, work with physician offices to reduce patients risks  Goal: control drug costs and improve patient safety and quality of care  G:\CorpSvc\APowerpnt\SM\Ed ONEIL 4BC BS 092006 Neurobehavioral Pain Management Program   Psychotherapists teach patients to „turn off‟ pain using mind and body focus rather than pharmacological Initial results – 30 days after completing program, participants report: - 71% suggest total pain reduction; 93% report at least some pain reduction; - 82% report total stress reduction; 97% respond with at least some stress reduction G:\CorpSvc\APowerpnt\SM\Ed ONEIL 4BC BS 092006 Clinical Snap-shots   Physician specific report designed to identify patients who have “fallen through the cracks”- lost to follow up or non-compliant with treatment plan Examples: – diabetics overdue for Alc and lipid tests – patients with hip fractures who are candidates for bisphosphonates  Hill contacts members, mails requisitions and reminders G:\CorpSvc\APowerpnt\SM\Ed ONEIL 4BC BS 092006 Helping Physicians Help Themselves  Finding Balance in a Medical Life - Teaches relaxation, cognitive restructuring, and meditation skills - 150 physicians participated with spouses - Third year; high levels of satisfaction - Expanded to office staff Point of Service on-line surveys - Provide doctors with access to immediate patient feedback - Aligns with IHA pay for performance - Evaluating additional potential uses G:\CorpSvc\APowerpnt\SM\Ed ONEIL 4BC BS 092006  Point of Service Online Surveys    Kiosks with internet connection are located in physicians‟ office waiting rooms. Patients log on anonymously and complete interactive touch screen surveys. Initial survey on patient satisfaction  Creates immediate feedback to office staff  Useful for physicians who scored poorly on annual survey and want to improve  Hill office outreach staff meets with practice manager to interpret results and suggest improvement projects. G:\CorpSvc\APowerpnt\SM\Ed ONEIL 4BC BS 092006 Practice Value Grid  Identified key practice attributes that create value to Hill Physicians to best allocate resources – – – – – – – – Large Hill patient base Performance on Utilization and Clinical Profiles Group Practice Multi-Sited Open to new patients Exclusive (PCP Only) Network Need Participation in Hill Initiatives G:\CorpSvc\APowerpnt\SM\Ed ONEIL 4BC BS 092006 Practice Support       Office manager assistance Physician recruitment Selected subsidies for new MDs I.T. assistance Growing menu of services Practice management? G:\CorpSvc\APowerpnt\SM\Ed ONEIL 4BC BS 092006 Physician Leadership Initiative  Program content and structure based on four levels of physician leadership that tie roles, tasks, and traits to performance  Two-year program with an average of 32 instruction hours per physician  Nomination-based program with class entry once per year  Continuing medical education credit  Leadership placement based on participation performance and learning evaluation  90-day; 6-month; and 1 year performance evaluation (self and other) G:\CorpSvc\APowerpnt\SM\Ed ONEIL 4BC BS 092006 Continued Emphasis on Doing the Little Things Right…   Customer Services ― 78% of calls answered in 30 seconds or less Claims - 70% of claims received electronically - Average speed to pay claims: 4 days - Health Plan Audit Results: 98% PriMed employees received, on average, 18 hours of training to improve skills and knowledge critical to their jobs. G:\CorpSvc\APowerpnt\SM\Ed ONEIL 4BC BS 092006  Physician Satisfaction Measured annually by independent survey group 88% 80% 76% 66% 83% 90% 2000 2001 2002 2003 2004 2005 G:\CorpSvc\APowerpnt\SM\Ed ONEIL 4BC BS 092006 Hill Physicians’ “Pay for Performance” Program Goals Promote results oriented culture  Expand the concept of medical services  Move to population management  Strengthen the overall organization  G:\CorpSvc\APowerpnt\SM\Ed ONEIL 4BC BS 092006 Making Physician Compensation Meaningful Primary Care Management Fee  Developed in 1997 as a vehicle to transform PCP compensation; some specialists added in 2004 Rewards efficient and innovative practices Performance based, population based Paid in addition to fee-for-service payments Quarterly distribution     G:\CorpSvc\APowerpnt\SM\Ed ONEIL 4BC BS 092006 Performance Based Profiles - PCPs Utilization / Controlling Costs professional pharmacy facility costs breast cancer screening cervical cancer screening diabetes HbA1c asthma medication childhood immunizations open practice panel meetings e-initiatives Hospitalist Program exclusivity Clinical Quality (P4P) Engagement Member satisfaction (annual) G:\CorpSvc\APowerpnt\SM\Ed ONEIL 4BC BS 092006 Pay For Performance $ Millions $24.7 $28.0 $17.7 $13.5 $5.8 $5.2 $3.6 $6.8 $1.7 $1.8 $3.8 $7.5 $4.8 $5.5 2000 2001 2002 2003 2004 2005 2006 Revenue Incentive Payments G:\CorpSvc\APowerpnt\SM\Ed ONEIL 4BC BS 092006 Impact  Increased physician satisfaction, participation and attention to clinical quality initiatives represents 15% of total PCP compensation: Average quarterly check per physician practice: % of practices receiving bonuses:  PMF $17,500 82% G:\CorpSvc\APowerpnt\SM\Ed ONEIL 4BC BS 092006 Expanding Program  Similar profile initiated for specialists – – – – GI ObGyn Surgery Ophthalmology Risk adjusters added in 2005  Continuously expanding metrics  G:\CorpSvc\APowerpnt\SM\Ed ONEIL 4BC BS 092006 Goal of P4P To create a compelling set of incentives that will drive breakthrough improvements in clinical quality and the patient experience through: √ Common set of measures √ A public scorecard √ Health plan payments Plans and Medical Groups – Who’s Playing? Health Plans* • • • • Aetna Blue Cross Blue Shield Western Health Advantage (2004) • CIGNA • Health Net • PacifiCare Medical Groups/IPAs  225 groups / 35,000 physicians 6.2 million HMO commercial enrollees * Kaiser Northern California participated in the 2005 scorecard Organizing Principles • Measures must be valid, accurate, meaningful to consumers, important to public health in CA, economical to collect (admin data), stable, and get harder over time • New measures are tested and put out for stakeholder comment prior to adoption • Data collection is electronic only (no chart review) • Data from all participating health plans is aggregated to create a total patient population for each physician group • Reporting and payment at physician group level • Financial incentives are paid directly by health plans to physician groups Program Governance • • • • Steering Committee – determine strategy, set policy Technical Committee – develop measure set IHA – facilitates governance/project management Sub-contractors  NCQA/DDD – data collection  NCQA/PBGH – technical support Multi-stakeholders “own” the program Measurement Domain Weighting Clinical Patient Experience IT Investment Individual Physician Feedback program 2003 50% 40% 2004 40% 40% 2005 50% 30% 2006 50% 30% 10% 20% 20% 10% “extra credit” 20% 10% “extra credit” Improvement X 2006 Clinical Measures • Preventive Care  Breast Cancer Screening  Cervical Cancer Screening  Childhood Immunizations  Chlamydia screening • Chronic Disease Care  Appropriate Meds for • Acute Care  Treatment for Children with Upper Respiratory Infection Persons with Asthma  Diabetes: HbA1c Testing & Control  Cholesterol Management: LDL Screening & Control  Nephropathy Monitoring for Diabetics  Obesity Counseling 2006 Patient Experience • Communication with doctor • Overall ratings of care • Care Coordination • Specialty care • Timely Access to care 2006 Information Technology • Measure 1 - clinical data integration at group level (i.e. population mgmt.) • Measure 2 - clinical decision support (point of care) to aid physicians during patient encounters For full credit, demonstrate four activities, with at least two in Measure 2 2006 Bonus Opportunities • Individual Physician Feedback Program • Improvement over previous year’s performance Results: Increased CAS Participation 180 160 140 120 100 80 60 40 20 0 2002 2003 2004 2005 63% increase P4P Year 1 Results: Improvement in all Measures • Improvement of 1.1 to 10.2 percentage points on all clinical measures – Statistically significant for all but one measure • Improvement of 0.5 to 2.2 percentage points on all patient experience measures – Improvement much greater (2.7 to 5.0 percentage points) for groups in CAS from the start • Dramatic increase in adoption of IT – More than half of physician groups have demonstrated IT capability Correlation Between IT and Clinical Quality Clinical Average by IT Total Score, Measurement Year 2004 80 75 70 65 60 55 50 0% 5% 10% 15% 20% IT Total Score Average Clinical Score Web-based Score Card www.opa.ca.gov Lessons Learned #1: Building and maintaining trust • Neutral convener • Transparency in all aspects of program • Governance and communication includes all stakeholders – Natural “tensions” between stakeholders creates accountability – Freedom to openly express ideas and concerns • Data collection and aggregation done by independent third party Lessons Learned #2: Securing Physician Group Participation • Uniform measurement set used by all plans • Significant, sustained incentive payments by health plans • Public reporting of results #3: Data Collection and Aggregation • Facilitate data exchange between groups and plans • Aggregated data is more powerful and more credible Key Issues Ahead • Increase health plan payments to up to 10% – Create “safe haven” to advance consistent payment methodologies • Develop and expand measure set – – – – – – Reward improvement Incorporate outcomes and specialty care Apply risk adjustment Add efficiency measurement Focus on “systemness” and processes of care Better Patient Experience measures • Include Medicare Advantage Macro Issues PPO siphoning of healthy patients/creating unaffordability of HMO product  Primary Care sustainability  Infrastructure development  Price competition at the provider level  G:\CorpSvc\APowerpnt\SM\Ed ONEIL 4BC BS 092006