bridges to excellence, proprietary & confidential bridges to excellence rewarding quality...
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Bridges To Excellence, Proprietary & Confidential
Bridges To ExcellenceRewarding Quality
Accelerating IT Adoption in Healthcare
Jeff Hanson, MPHRegional Healthcare Manager, Verizon Communications
Board President, Bridges to Excellence
HIT Summit West
San Francisco, CA
March 8, 2005
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AGENDA
• Quality Imperative – Employer’s View• Program Structure• Results• Consumer Engagement• Lessons Learned
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Employer Perspective: “Change is Necessary”
• Compelling Stats280,000 people will get the wrong advice today in a
doctor’s office2,800 people will be harmed today by a medication errorEquivalent of 390 fully-loaded 747’s will die this year in
the hospital from a preventable medical mistake – >1 747/day
Many of these will be our employees
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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 it’s been known for a decade that these drugs provide life-saving benefits
Translation of medical research into practice is slow—average of 17 years
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Quality: Missing the Mark
Source: NEJM 2003 348:2635-45
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Employer Perspective – Potential for Cost Savings
0% 5% 10% 15% 20%
Potential savings using best practices
18%Efficient Providers
16%Effective Providers
4%Plan Administration
Plan Design 7%
The Business Roundtable and William M. Mercer, 2002
0% 5% 10% 15% 20%
Potential savings using best practices
18%Efficient Providers
16%Effective Providers
4%Plan Administration
Plan Design 7%
18%Efficient Providers 18%Efficient Providers
16%Effective Providers 16%Effective Providers
4%Plan Administration 4%Plan Administration
Plan Design 7%Plan Design 7%
The Business Roundtable and William M. Mercer, 2002Time to change focus …without losing sight of
reality
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Employer Perspective: Improved Effectiveness Leads to Cost Savings
Incentives
$
Greater Effectiveness
HealthierPatients
Cost Savings
Preventive Screening
Disease Management
Clinical Information Systems
Fewer Complications
Fewer Medical Errors
Reduced Health Care Costs
Increased Productivity
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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
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Multi-stakeholder approach to creating incentives for qualityEmployers, 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 careDemonstrate the reengineering is working through better outcomes for patients with chronic conditions, starting with diabetes and cardio-vascular diseasesProgram costs paid by participating employers
BTE – What is Bridges To Excellence?
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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 we’re after is a significant reengineering in the processes of care.
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BTE: Overall Concept
Employers CommitWithin Market
• Collaboration
• Critical Mass
Health PlansSupply Data
• Patient Counts per Physician
PhysiciansNotified
• Reward Potential
• Next Steps
PracticesApply
• NCQA Web site
• Application Fees
PracticesRecognized
• NCQA
• 3-yr
PracticesRewarded
• Rewards Based on Patient Counts
• Fees Reimbursed
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BTE uses nationally recognized physician recognition programs
Structure (PPC):
Process & Outcomes (DPRP & HSRP):
HbA1Cs tested and controlledLDLs tested and controlledBP tested and controlledEye, Foot and Urine exams
LDLs tested and controlledBP tested and controlledUse of aspirinSmoking cessation advice
Patient safety – e-prescribingGuideline-driven care – EHRsFocus on high-cost patients – Care coordinationImproved compliance – Patient education & support
NCQA
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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
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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.
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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
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Summary of Performance 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 < 7% 40%
Proportion HbA1c > 9.0% 20%
# Eye exams 60%
# Foot Exam 80%
# Blood Pressure Frequency 97%
Proportion < 140/90 mm Hg 65%
# Nephropathy Assessments 80%
# Lipid Profiles 85%
LDL <130 mg/dl 63%
LDL <100 mg/dl 36%
Smoking Status/Cessation Cnsl. 80%
80%# Lipid Profiles Done in last 12 mos
50%LDL <100 mg/dl
80%Patients with aspirin or other antithrombotics use
80%Smoking status & cessation advice
75%Proportion < 140/90 mm Hg
80%# Blood Pressure Testing in last 12 mos
Req. % of Patients
Achieving Measure
Cardiac Care Link Measures
Physician Office Link (PPC) Measures
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BTE IncentivesOffices meeting Passing Score in:
POL DCL/CCL
Clinical Information
System
Patient Education &
Support
Care Management
Any Module
Y1 $50 20% of bonus is withheld until
practice meets DCL and/or CCL (depends on
whether attribution id’s diabetics and/or
cardiac patients)
Doc gets full POL bonus plus extra
$80 for each diabetic and cardiac
patient when meeting CCL/DCL
Y2 $20
Y3 $10
Two out of three Modules
Y1 $50
Y2 $50
Y3 $30
All three Modules
Y1 $50
Y2 $50
Y3 $50
A top scoring practice can earn up to $20K per doc/year
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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 patients2.5% 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)
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BTE is live in four markets
Cincinnati, OH /Louisville, KY
Boston, MAAlbany /
Schenectady, NY
Launch Date June 2003 February 2004 May 2004
Program(s) DCL DCL, POL POL, DCL, CCL
# of Employers
7: GE, Ford, UPS, P&G, Humana, CCHMC, City of Cinci
3 (6): GE, Raytheon, Verizon, (IBM, AZ)
4: GE, Hannaford Bros, Verizon, Golub
# of Plans6: 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)
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We’ve made great progress in all our pilot markets already
Jan 2004 Jan 2005
Recognized
Physicians
PPC 30 475
DPRP 60 361
Employees going to recognized Physicians
DPRP 1,742
PPC 8,872
Rewards paid to-date $1.07M
Available Rewards $8MM
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Results to Date
CUMULATIVE
BTE Recognized & Rewarded Physicians DCL POL CCL
Market Recg Rwd Recg Rwd Recg Rwd
Cincinnati 65 63 Louisville 27 26 Boston 233 96 465 447 NY Capital Region 36 7 10 10 0 0 Total 361 192 475 457 0 0
BTE Bonus Earned Market DCL POL CCL Total Cincinnati $98,615 $98,615 Louisville $96,955 $96,955 Boston $45,832.32 $759,278.53 $805,110.85 NY Capital Region $7,040 $61,320 $0 $7,040 Total $248,442.32 $820,598.53 $0 $1,007,720.85
Employer Patients Seeing NCQA Recognized Physicians
DCL POL CCL Cincinnati # Elig. % # Elig. % # Elig. % Cincinnati 924 5405 17.5% Louisville 342 3767 9.1% Boston 411 3664 11.2% 8043 86297 9.3% NY Capital Region 65 2093 3.1% 829 43585 1.9% 0 968 0.0.% Total 1742 14929 11.7% 8872 129882 6.8% 0 968 0.0.%
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We’re continuing a rigorous evaluation, but we’ve 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 don’t know:– Are POL docs more efficient? We’re 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? We’re also getting the answer from two sources:
• Ingenix & CFP
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And they also have lower costs of care, whether episodes or total costs
$1,250
$1,300
$1,350
$1,400
$1,450
$1,500
$1,550
$1,600
$1,650
Diabetes Costs Only
Non-recognized Physicians Recognized Physicians
$5,350
$5,400
$5,450
$5,500
$5,550
$5,600
$5,650
$5,700
$5,750
$5,800
All Costs
Non-recognized Physicians Recognized Physicians
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Why BTE – Employer Perspective
Financial DPRP savings est. 15% or ~$1,000 pppy (medical only) ROI >10% 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
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Rewarding Active Consumers: CareRewards
•Four-step processCreate 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
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Links to:• MD search to find recognized MD’s• Leapfrog Website for hospital safety data• Newsletters, news, clinical trials and additional health info
Employer specific content
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Earning and Redeeming Points
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Rewards Customizable by Employer
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Consumers are also engaged through our physician report card web site
High-level roll-up of physician’s overall performance
Distinguishes relative performance of physicians within each level
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Effectiveness results come from NCQA, patient experience of care from employees
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Lessons Learned/Challenges/Opportunities Provider report cards are disliked by almost all providers
BTE’s 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
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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
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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 agreementsBuy-in by physician community
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BTE Markets
BTE Interest
•4 UHC markets
•2 Employer specific
•3 BCBS Plans
•Remainder – Coalition based
There are 13 additional markets that have actively expressed interest in BTE
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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
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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%
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We’re going to continue building programs to cover most specialties
•2007•2006•2005PPC version 2.0 +
All Docs
PCPs (IM, FP, Gyn, Ped, etc.)
PCP Recognition Program
Patient Experience of Care
Ortho & Rheum MSK RP
Oncologists Cancer RP
Endo DPRP
Cardio & Neuro HSRP
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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
BTE Summary
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Resources
Bridges to Excellence.
www.bridgestoexcellence.org National Committee for Quality
Assurance.
www.ncqa.org The MEDSTAT Group.
www.webmdhealth.com National Business Coalition on Health
www.nbch.org