evidence based medicine and value based purchasing

8/12/2019 Evidence Based Medicine and Value Based Purchasing

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Healthcare Operations Management 2008 Health Administration Press. All rights reserved.

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Chapter 3

Evidence-Based Medicine andPay for Performance


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The Challenge of Medical Progress

Medical progress Laboratory experiments

Clinical trials

Translation to clinical practice

However, translation to practice is poorlyexecuted Structural, motivational, economic barriers

Resultwidespread variation in practice andinconsistent quality


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Evidence-Based Medicine (EBM)

The cure to wide variation in clinical practice: theconsistent application of EBM

Major tool: the clinical guideline (also known as a

protocol) Institute of Medicine definition: systematically

developed statements to assist practitioner andpatient decisions about appropriate health care forspecific clinical circumstances

National Guideline Clearinghouse 4,000 guidelines

http://www.guideline.gov


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Resistance to Evidence-BasedMedicine

Disagreement on the science underlying a

guideline Challenge to professional autonomy

cookbook medicine

Lack of variation in treatment approachesdecreases natural discoveries


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Custom and Standard Care

All clinical care is a mix of custom and

standardized care processes High-quality organizations

Master the art of custom care

Optimize the science and consistent deliveryof standard care


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Custom

Custom and Standard Health Care

Separate and Select

Standard Sorting Re-sorting

Examples:

Laser eye surgery

Minute clinic

Patients self-select

Source: Bohmer, Richard. 2005.

Medicines Service Challenge:

Blending Custom and Standard

Care.Healthcare Management

Review Oct.Dec.


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Custom

Separate and Accommodate


Example: Duke Cardiology Clinic

Patients sorted by protocol

Nurse practitioners provide

standard care

Cardiologists provide custom

careEvery fourth visit, standard

patients are evaluated by the

nurse practitioner and

physician


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Custom

Modularize


Example: Andrews AFB Clinic

Physician serves asarchitectcare designer

Physician performs evaluation

and creates plan

Standard care provided byother organizations and

departments

Hypertension modules: weight

control, diet, drug therapy,

stress modification,surveillance


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Custom

Integrated


Example: Intermountain Healthcare

Identified 62 standard

processes90 percent of

inpatients

Standard processes built into

emergency medical record

Physician encouraged tooverride standard care as

needed

Overrides are recorded,

analyzed, and used to

improve standard process


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Financial Implications of EBM

Savings in the system can be achieved by

consistent, high-quality ambulatory care, which

prevents unneeded hospital admissions

AHRQ has identified a set of ambulatory care

sensitive conditions, which are measured with

prevention quality indicators (PQIs)


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Prevention Quality Indicators

1 Diabetes short-term complication admission rate

2 Perforated appendix admission rate

3 Diabetes long-term complication admission rate

4 Chronic obstructive pulmonary disease admission rate

5 Hypertension admission rate6 Congestive heart failure admission rate

7 Low birth weight

8 Dehydration admission rate

9 Bacterial pneumonia admission rate

10 Urinary tract infection admission rate11 Angina admission without procedure

12 Uncontrolled diabetes admission rate

13 Adult asthma admission rate

14 Rate of lower-extremity amputation among patients with diabetes


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Strategies for Implementing EBM

Case management

Guidelines adopted by the group and available

in the chart Feedback to physicians on the care they

deliver compared to guideline-recommendedcare

Disease registries to track patients with chronicconditions


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Strategies for Spreading

the Use of EBM

Public reporting

Pay for performance

Tiered systems of care


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Public Reporting

CMS reporting

Hospitals Long-term care

Medical groups

Community-based systems


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Issues in Public Reporting

Risk adjustment for sicker patients

Patient compliance Measurement of individuals or clinics

Use by general public to make buying

decisions


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Strategic Issues for theSuccess of Public Reporting

1. Quality problems are real; quality can beimproved

2. Quality reporting is standardized3. Information is relevant to consumers and easy

to understand

4. Dissemination is optimized

5. Quality improvement efforts by providers needto be rewarded


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Pay for PerformanceKey Issues

Goal: improved health outcomes and loweredcosts through use of EBM

How is pay for performance funded?

Another form of withholding

Savings on prevented inpatient care Reward top performance or improvement?

Risk adjustment

Administrative and other system improvement

costs (electronic health record changes) Focus on compliant patients only

Discourages care of complex patients


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Pay for PerformanceExamples

Bridges to Excellence

Diabetes

Cardiac care

Integrated Healthcare AssociationCalifornia

CMS Premier Hospital Demonstration

Project


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Tiering

Buyer or health plan analysesproviders and assigns them to a tier

Tiering is based on cost, quality, or

both Each tier has a differential price to

the patient

Monthly premium cost Deductible and co-pays


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Tiering Example:Minnesota Advantage

Tier Individual Family

1 $30 $60

2 $100 $200

3 $280 $5604 $500 $1,000

Minnesota Advantage Health Plan Annual

First-Dollar Deductible, 2006


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Tiering Example:Minnesota Advantage

Number of Primary Care Clinics in Each Payment Tier

for Minnesota Advantage, 2004 and 2006

0

100

200

300

400

500

600

Tier 1 Tier 2 Tier 3 Tier 4

2004

0

200

400

600

800

1000

1200

Tier 1 Tier 2 Tier 3 Tier 4

2006


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Summary

The use of EBM is increasing

It has been demonstrated that EBM canincrease quality and decrease costs

Efforts to increase the use of EBMinclude:

Public reporting

Pay for performance

Tiering


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End of Chapter 3

evidence based medicine and value based purchasing

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