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TRANSCRIPT
Physician P4P Programs: Leveraging Data to Identify Opportunities for Cost
and Quality Improvement
Fifth National Pay For Performance Summit March 9, 2010
Colleen Thilgen, Vice President, Ingenix ConsultingMichael van Duren, M.D., CMO, Sutter Physician Services
Overview
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• Our Current Reality
• Now What?
• Case Study – Sutter Medical Network
Our Current Reality
Unsustainable Growth
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Source: OECD Health Data 2009
2009 suggests it’s just getting worse …
Is More Better?
• “Quality health care means doing the right thing at the right time in the right way for the right person and having the best results possible”. AHRQ
• How do we rank?> Lower 1/3 of developed countries in life expectancy at birth> Highest rate of deaths from conditions that could have been
prevented or treated (among 19 countries studied)> Higher prevalence of cancer, heart disease, stroke in age 50+
population (in comparison to 10 European countries)> Second highest in adult hospital admission rates for asthma
(among 17 countries reporting)
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Source: How Does the Quality of U.S. Health Care Compare Internationally?, RWJF, August 2009
• Dartmouth Atlas Project studies• Bringing it mainstream: Atul Gawande June 2009 New
Yorker1
• Studies continue …> NCQA: Less than 1% of radiographs find the cause of low back
pain.2
> Recent study of 2006 hospital costs for Medicare beneficiaries3
• Range for typical CHF patient: $1,522 to $18,927• Range for typical patient w/pneumonia: $1,897 to $15,829
Variation
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1 Gawande A, The cost conundrum: what a Texas town can teach us about health care, The New Yorker, June 1, 2009.2 NCQA, State of Health Care Quality 2009. 3 L. M. Chen, A. K. Jha, S. Guterman et al., The Hospital Cost of Care, Quality of Care, and Readmission Rates: Penny-Wise and Pound-Foolish, Archives of Internal Medicine, Feb. 22, 2010 170(4):340-346..
Variation
Distribution of Quality and Cost of Care Composite ResultsSpine and Orthopaedic Surgeons
0.80
0.90
1.00
1.10
1.20
0.60 0.70 0.80 0.90 1.00 1.10 1.20 1.30 1.40
Relative Efficiency Score (x-axis)
Rel
ativ
e Q
ualit
y Sc
ore
(y-a
xis)
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Source: 2008 Ingenix Study
Impact on Consumers
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“Transparency should not be a luxury; it’s a matter of life and
death”
2009 Average Premium for Family
Health Care Coverage --
$13,375
Increases over past decade:
•Wages –
38%•Inflation –
28%
HC Premiums –
131%
Source: U.S. Department of HHS
Source: Kaiser Family Foundation
Now What?
Increased Focus On …
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Impact on Providers
• Increasingly being measured and compared• Asked to assume greater financial risk
> Payment designs (bundled payments, capitation)> Value-based purchasing (P4P)> Accountable Care Organizations
• Also comes with opportunities> Shared savings> Improved margins> Recognition as a high performer – both excellence and affordability> More patients, better-served patients, happier patients
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Provider Organization Needs
• Trusted and transparent performance metrics> Quality> Efficiency
• Reliable and complete data• Efficient processes for applying data to
metrics• Access to information at the right level
> Reports and strategies that drive to actionable information – “guided analytics”
• Experience and collaboration to leverage results for improvement
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Metrics – Quality
•Meaningful•Measurable•Actionable
Comparison of patient experience to guidelines and best practice
Quality Metrics Example Rules for CHF*
Sample Guidelines for CHF Compliance Flag
Patient(s) taking an ACE-inhibitor or acceptable alternative Yes
Patient(s) taking a beta-blocker No
Patient(s) compliant with prescribed ACE-inhibitor (minimum compliance 70%) No
Patient(s) compliant with prescribed beta-blocker-containing medication (minimum compliance 70%) N/A
Patient(s) taking ACE-inhibitor that had serum potassium test in last 12 reported months Yes
Patient(s) that had an annual physician visit Yes
Jan Dec
Office VisitDx. CHF
Office VisitDx. CHF
Lab Serum K Rx ClaimsACE Inhibitor30 Day Supply
Rx ClaimsACE Inhibitor30 Day Supply
* Ingenix Symmetry Evidence-Based Medicine (EBM) Connect© Ingenix, Inc. 13
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Metrics – Efficiency
• Population measures> Services for a defined population> Applications for ACOs, global risk and medical
home scenarios
• Episodes of care> A unique condition for a patient and the services
involved in diagnosing, managing and treating that condition
> Wide range of applications, in particular evaluating specialists
• Valid methods for adjusting for differences in comorbidity, complications and severity a must
Episode Example Acute Bronchitis with Co-morbidities*
Clean PeriodStart
Clean PeriodEnd
Office Visit (Anchor Record)
Lab Services (Ancillary Record)
Radiology (Ancillary)
Pharmacy Records (Ancillary)
Cluster 1PCP #1
Cluster 2 Specialist A
Cluster 4PCP #1
Cluster 3 Specialist A
Insulin Diabetes
• All records in the episode share the same unique episode number• Episodes for the same condition can vary by level of severity
* Ingenix Symmetry Episode Treatment Groups (ETGs)© Ingenix, Inc. 15
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Assigning Episode Severity
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Applying the Metrics
• Selecting physicians to be compared, creating “peer” groups
• Selecting episodes, quality rules and metrics for each peer group
• Attributing episodes and patients
• Risk adjusting for differences in patient morbidity or case mix
• Creating measures at different levels, designating performance and sharing results
Measuring Performance - Solution Overview
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BI SolutionRobust Data Mart & Reporting
System
Analytics delivered in the appropriate context to drive
improvement
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Challenges for a Provider Organization
• Identifying objectives
• Engaging stakeholders
• Selecting methods and measures
• Getting the data – to support sample size and benchmarks
• Applying the metrics
• Understanding opportunities for improvement
• Communicating results and enabling change
• Measuring success
Provider Measurement
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Case Study Sutter Medical Network
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Key Takeaways
• Increased focus on provider measurement• More risk, more opportunity• Need for data-driven decision making• Ultimate goal – improve patient care
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Questions?
Colleen Thilgen
Michael van Duren, M.D.