national behavioral consortium portland, oregon june 2007

National Behavioral Consortium

Portland, Oregon June 2007

Rick Weisblatt, PhD

Harvard Pilgrim Health Care

Harvard Pilgrim Overview

Harvard Pilgrim Health Care

Not-for-profit health plan licensed to do business in New Hampshire, Massachusetts and Maine Over 1million members as of January, 2007

Solid financial performance in a highly competitive marketplace

Expanded portfolio of self funded options with acquisition of Health Plans, Inc.

A year of national and local accolades – “Best Place to Work” in 2005 from Boston Business Journal

Top Leadership Team 2005 in healthcare by HealthLeaders Magazine

US News and World Report / NCQA : #1 Health Plan in America 3rd year running

Behavioral health partner – United Behavioral Health

Harvard Pilgrim range of products

Comprehensive Product Portfolio: Harvard Pilgrim HMO

Harvard Pilgrim POS

Harvard Pilgrim PPO

Harvard Pilgrim HSA PPO Plans

HPHC Definity HRA Plans

Including the more affordable… Harvard Pilgrim Best Buy HMO Harvard Pilgrim Tiered-Copay HMO Harvard Pilgrim NetOption NH HMO Harvard Pilgrim Best Buy POS

Available on both Fully and Self-insured funding arrangements

Market Context

Utilization increases continue

Provider rate demands unabated

Technology advances at a dizzying clip

Not enough teeth in Evidence Based Medicine

Provider-level performance measures still primitive

Busy providers have little incentive to negotiate

Managed care “tools” eliminated or have run their course

Medicare and Medicaid continue to be “under-funded”

States look to health plans to fund budget shortfalls

Purchasers and consumers are cognitively dissonant

Utilization increases continue

Provider rate demands unabated

Technology advances at a dizzying clip

Not enough teeth in Evidence Based Medicine

Provider-level performance measures still primitive

Busy providers have little incentive to negotiate

Managed care “tools” eliminated or have run their course

Medicare and Medicaid continue to be “under-funded”

States look to health plans to fund budget shortfalls

Purchasers and consumers are cognitively dissonant

The marketplace is kind of a mess…

Medical Trends Medical Trends

Aging population Patient demand Chronic illness – prevalence, longer life expectancy New technologies Pharmacy industrial complex Supply-driven market Fragmented care system Regulation

Target high ROI areas

Maximally leverage the member

Multi-pronged approach

Align everyone’s incentives

Drive evidence-based practice

Bring clinical IT into the 21st century

Public disclosure of meaningful data

Health plan responseHealth plan response

High

Low2002 2012

Value of Health

Benefits

Impact on Americans

Key Evolutionary Steps

Performancecomparisons

For hospitals, MDs & Tx

Market sensitivity to performance

ClinicalRe-engineering

By MDs,hospitals

Quality Costs

PerformanceDisclosure

Consumerism & Payfor Performance

Care SystemResponse

Source: Arnie Milstein

Value TransformationValue Transformation

Behavioral Health in 2007

Just some of the issues…

Patient protection and appeals rights

Coverage mandates and expansion

Parity

Cost shifting from states

Carve in vs. Carve out

Managing Utilization: Wennberg & Fisher’s: Categories of Medical Care

Effective care and medical error

Preference-sensitive care

Supply sensitive care

Supply-Sensitive Care – Capacity Determines use

Strongly correlated with resource supply

Examples include medical admissions, ICU stays, physician visits, specialty referrals, lab and radiology testing, especially in the last six months of life

Medical evidence weak or non-existent; patient preferences and values should play a significant role

Supply-Sensitive Care : Highest vs Lowest Spending Regions

1.00 1.5 2.00.5 25 3.0

1.00 1.5 2.00.5 25 3.0

Office Visits

Initial Inpatient Specialist ConsultationsInpatient Visits

Psychotherapy Visits% of Patients seeing 10 or more MDs

Physician Visits

Electrocardiogram

Ambulatory ECG (Holter)Echocardiogram

Diagnostic Cardiology Procedures

Lower in High Spending Regions Higher in High Spending Regions

Chest X-ray

Ventilation Perfusion ScanCT / MRI Brain

Imaging Tests

HEDIS National Performance Trends

Follow Up within 7 days

0.010.020.030.040.050.060.070.080.0

2002 2003 2004 2005 2006

% C

ases Mean

90th %ile


Follow Up within 30 days

65.0

70.0

75.0

80.0

85.0

90.0

2002 2003 2004 2005 2006

% C

ases Mean

90th %ile


AntiDepressant - Contact

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

2002 2003 2004 2005 2006

% C

ases Mean

90th %ile


AntiDepressant - Acute

0.010.020.030.040.050.060.070.080.0

2002 2003 2004 2005 2006

% C

ases Mean

90th %ile


AntiDepressant - Continuation

0.0

10.0

20.0

30.0

40.0

50.0

60.0

2002 2003 2004 2005 2006

% C

ases Mean

90th %ile

Harvard Pilgrim

Pay for Performance and

Recognition Programs

Impacting Provider Performance

Transparency and Disclosure

Public Reporting and Consensus Measures

Rewards and Recognition

Pay for Reporting

Pay for Performance

Strategic Quality InitiativesCollaborate with key partners on QI initiatives

Rewards for Excellence: OUTCOMESReward practices for achieving desired outcomes

Shared Savings/EfficiencyShare savings based on efficient use of providers/services

Clinical Information TechnologyInvest in CIT to improve care processes, outcomes, and efficiency

Rewards for Excellence: PROCESSReward consistent performance in key care processes

Quality Grant ProgramImplement local QI programs, aligned with HPHC's QI Plan

Infrastructure FundingImplement basic practice management elements

Medical Director Stipendget an engaged clinical partner

Evolution of Practice Capabilities

Evolution of Quality Incentive Programs

Overview of P4P

Encourage and reward investments and improvements in clinical outcomes and clinical infrastructure

Primary Messages: Recognizing Excellence and Rewarding Improvement

Recognition of need to clearly support medical group administration (Medical Director and Administrative Stipend)

Use of efficiency measures such as lab Steerage and Tier 1 prescribing

Introduction of outcomes based performance, focusing on clinical values for Diabetes HbA1c and LDL measures

Performance measures structured to align with various practice types and within various contract models

Quality Advance Program

Introduced in 2004

Complemented HPHC’s shift away from risk based contracts – provided “upside bonus ” for high quality care

Portfolio of elements developed through the evolution of P4P

Practices can earn up to $4.25 pmpm in 2006

Quality Advance Program 2006Med. Dir. Stipend Supports Medical Directory role, described in contract

Practice Admin Stipend Supports group’s infrastructure

Efficiency/Shared Svgs: Lab/Path

Promotes use of cost- effective lab providers

Efficiency/Shared Svgs: Tier 1 Rx %

Promotes Tier 1 drug prescribing

Clinical Information Technology (CIT)

Promotes adoption of systems to manage patient populations and improve safety- registries, EMR, CPOE – consistent with Institute of Medicine guidelines

Rewards for Excellence (R4E)

Rewards LCUs for excellent performance (national 90th percentile) on selected HEDIS measures. In 2006, bonus for Diabetes outcome values (HbA1c and LDL).

Quality Grants Program

Unique to HPHC; valued by the physician and employer communities

Since 2000, 109 grants awarded for $8.6M Proposals aligned with IOM quality goals, on a topic of

strategic importance to HPHC HPHC Medical Leadership and Harvard Pilgrim

Physician Association Board review proposals Funding based on practice membership and project

scope ($25K-$125K)

2006 Quality Grants Program

19 grants awarded to MA, NH, ME practices (out of 32 proposals)

Topics: Health IT (10), Reducing Disparities in Healthcare (5), Depression (3), ADHD (1)

Total funding: $1.3 million

Grant synopses posted on HPHC Provider site

HPHC Honor RollPhysician Group Honor Roll- Adult & Pedi (since ‘03) An Adult practice must show performance above the national 90th

percentile in at least 9 of 11 HEDIS measures. A Pediatric practice must show performance above the national 90th

percentile in at least 4 of 5 HEDIS measures. Recognition on HPHC member site:

Practice name listed Icons in provider directory for PCPs in these practices

Hospital Quality Disclosure Designed to show excellence in CMS, JCAHO, and Leapfrog measures HPHC has adopted the N.H. Foundation for Healthy Communities data set

for reporting NH hospitals

And CMS is getting into the game

From presentation by Regional CMS Administrator Dr. Charlotte Yeh on April 2,

2007

CMS as a Public Health Agency

Vision: To achieve a transformed & modernized health care system Accurate & Predictable Payments

High Value Health Care

Confident Informed Consumers

Collaborative Partnerships


2007

Physician QualityReporting Initiative (PQRI) Eligible Professionals

Practitioners described in Social Security Act (SSA) Section 1842(b)(18)(C)

• Physician Assistant• Nurse Practitioner• Clinical Nurse SpecialistClinical Nurse Specialist• Certified Registered Nurse Anesthetist • Certified Nurse-Midwife • Clinical Social WorkerClinical Social Worker• Clinical PsychologistClinical Psychologist• Registered Dietitian• Nutrition Professional


2007

Physician QualityReporting Initiative (PQRI)

Quality Measures 74 “2007 PVRP” quality measures posted on December 5, 2006 adopted in

statute

Final list of 74 PQRI quality measures posted at www.cms.hhs.gov/PQRI, as a download on the Measures/Codes webpage

Antidepressant medication during acute phase for patients with new episode of major depression:

Acute phase defined as 12 weeks. 18 years and older.

Participating eligible professionals who successfully report may earn a 1.5% bonus, subject to cap


2007

CMS looking at efficiency as well

Efficiency Is One of the Institute of Medicine's Key Dimensions of Quality

1. Safety

2. Effectiveness

3. Patient-Centeredness

4. Timeliness

5. Efficiency: absence of waste, overuse, misuse, and errors

6. Equity

• Institute of Medicine: Crossing the Quality Chasm:

A New Health System for the 21st Century, March, 2001.


2007

CMS’ Cost of Care Measure Development

CMS’ Cost of Care Measurement Goals

To develop meaningful, actionable, and fair cost of care measures of actual to expected physician resource use

Evaluate episode grouper software as measurement tool

To link cost of care measures to quality of care measures for a comprehensive assessment of physician performance


2007

Bringing pay for performance to the behavioral health

community

Considerations for Behavioral Health P4P

Set the stage for accountability Promote consensus measures HEDIS and CMS Clinician reporting Public reporting Recognition programs Incentives: financial and administrative

Issues

Self-reported specialties and credentialing

Lack of consensus outcomes measures

Groups practice vs. individual cottage industry

Privacy, patient protection and appeals

Parity

Some measure possibilities

Generic prescribing

Poly-psychopharmacology

Visits/member/year; risk and diagnosis adjusted

Outcomes tools

HEDIS Behavioral Health

Incentives

Honor Roll and Report Card

Self management

Steerage

Fee schedule inflator or flat dollars/unique member treated

Incentive programs for B.H. providers UBH/PBH ALERT outcomes tool: steerage with pilot for financial incentive. Anthem: Coordination of care, CD treatment planning, patient satisfaction, HEDIS. Mass. Behavioral Health Partnership (Medicaid): Training in motivational interviewing for CD, inpatient LOS, use of outcomes tool (B.H. Labs). State of Delaware: CD measures including treatment continuation. Hawaii BCBS with major provider group: HEDIS measures, process measures.

national behavioral consortium portland, oregon june 2007

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