Innovative Health Care Policies: Using ACO Principles and Financial Incentives

to Improve Health Outcomes

Web SeminarWeb Seminar

January 29, 2013January 29, 2013

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Judi ConsalvoJudi Consalvo

Program Analyst at AHRQ Center Program Analyst at AHRQ Center for Outcomes and Evidencefor Outcomes and Evidence

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What Is the Health CareWhat Is the Health CareInnovations Exchange? Innovations Exchange?

Publicly accessible, searchable database of health policy Publicly accessible, searchable database of health policy and service delivery innovationsand service delivery innovations

Searchable QualityToolsSearchable QualityTools Successes and attemptsSuccesses and attempts Innovators’ stories and lessons learnedInnovators’ stories and lessons learned Expert commentariesExpert commentaries Learning and networking opportunitiesLearning and networking opportunities New content posted to the Web site every two weeks New content posted to the Web site every two weeks

Sign up at Sign up at http://http://www.innovations.ahrq.govwww.innovations.ahrq.gov under “Stay under “Stay Connected”Connected”

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Next EventsNext EventsJoin our Tweetchat – February 27, 2013Join our Tweetchat – February 27, 2013Chats on Change: Supporting Priority PopulationsChats on Change: Supporting Priority Populations

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Today’s Event ModeratorToday’s Event Moderator

Gerry Fairbrother, PhDGerry Fairbrother, PhD

Senior Scholar at AcademyHealthSenior Scholar at AcademyHealth

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Identifying Health Care Identifying Health Care Policy InnovationsPolicy Innovations

AcademyHealth is pleased to work with AcademyHealth is pleased to work with Westat and AHRQ on identifying health Westat and AHRQ on identifying health care policy innovationscare policy innovations

Major policy innovations in 2013: Major policy innovations in 2013: Accountable Care Organizations, Accountable Care Organizations, payment reforms, quality improvement payment reforms, quality improvement initiativesinitiatives

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Innovations Presented Innovations Presented TodayToday

The Blue Cross Blue Shield of Michigan The Blue Cross Blue Shield of Michigan and Montefiore Medical Centerand Montefiore Medical Center

A payer driven quality improvement A payer driven quality improvement initiative and an ACOinitiative and an ACO

Both timely and cutting edge innovationsBoth timely and cutting edge innovations

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David Share, MD, MPHDavid Share, MD, MPH

Blue Cross Blue Shield of Blue Cross Blue Shield of MichiganMichigan

Lauren Henrikson-Lauren Henrikson-Warzynski, MPAWarzynski, MPA

Health Care AnalystHealth Care AnalystSenior Vice President of Senior Vice President of

Value PartnershipsValue Partnerships11

Improving Healthcare Through Improving Healthcare Through Collaborative PartnershipsCollaborative Partnerships

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What are Collaborative What are Collaborative Quality Initiatives?Quality Initiatives?

Structure of Collaborative Quality Initiatives Structure of Collaborative Quality Initiatives (CQIs): developed and administered by (CQIs): developed and administered by Michigan physician and hospital partners, Michigan physician and hospital partners, funded by BCBSM and its HMO, Blue Care funded by BCBSM and its HMO, Blue Care NetworkNetwork

Support continuous quality improvement and Support continuous quality improvement and the development of best practices the development of best practices

Leverage inter-institutional data registriesLeverage inter-institutional data registries Why? Reduce avoidable adverse events, Why? Reduce avoidable adverse events,

provide incentives and track performanceprovide incentives and track performance

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Why Do We Need CQIs?Why Do We Need CQIs?

Quality of health care remains suboptimal, Quality of health care remains suboptimal, with wide variations in performance across with wide variations in performance across institutions and avoidable adverse events institutions and avoidable adverse events

Suboptimal quality affects patients’ health; Suboptimal quality affects patients’ health; drives up costs drives up costs

Regional collaborations can provide incentives Regional collaborations can provide incentives and infrastructure to systematically track and and infrastructure to systematically track and improve performanceimprove performance

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Overall Goals Overall Goals of the CQI Programof the CQI Program

Examine the link between care processes and Examine the link between care processes and outcomes in complex, highly technical areas of careoutcomes in complex, highly technical areas of care

Measure the quality of care within and across Measure the quality of care within and across systems systems

Create a feedback loop for continuous quality Create a feedback loop for continuous quality improvement with participating institutions improvement with participating institutions

Identify “clinical champions” at each participating Identify “clinical champions” at each participating hospital hospital

Implement fast-track quality improvement initiatives Implement fast-track quality improvement initiatives targeted at specific, high-leverage procedurestargeted at specific, high-leverage procedures

Continue to demonstrate to consumers and Continue to demonstrate to consumers and purchasers of care that CQIs positively impact purchasers of care that CQIs positively impact systems of caresystems of care 15

The BeginningThe Beginning

Collaborative study on the variation in angioplasty Collaborative study on the variation in angioplasty procedures and treatment (1997)procedures and treatment (1997)

Resulted in decreases in mortality, kidney failure, Resulted in decreases in mortality, kidney failure, emergency bypass surgeries and other emergency bypass surgeries and other complications complications

Fostered development of a culture in which Fostered development of a culture in which stakeholders pool efforts and best thinking to stakeholders pool efforts and best thinking to optimize practices, systems and outcomes of careoptimize practices, systems and outcomes of care

Collaboration was necessary for real changeCollaboration was necessary for real change

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Current CQI ProgramsCurrent CQI Programs

BCBSM/BCN Collaborative Quality Initiatives

Hospital-based 12

New Hospital-based (2013) 2

Hospital/Provider-based 1

Professional 5

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CQI Program FrameworkCQI Program Framework

• Offer neutral ground for collaboration

• Program funding and incentive payment design

• Clinical leadership• Analytic and quality

improvement support

CQI

Continuous Quality

Improvement

• Contribute to the all-payer registry

• Share and learn from best practices

Consortium

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CQI Financial SupportCQI Financial Support

Hospital CQIs: Hospital CQIs: Data collection for BCBSM/BCN, Medicare and Data collection for BCBSM/BCN, Medicare and

Medicaid, and uninsured members (estimated Medicaid, and uninsured members (estimated 80% of data collection costs)80% of data collection costs)

The CQI Coordinating CenterThe CQI Coordinating Center

Professional CQIs:Professional CQIs: Registry-based CQIs: Data collection for Registry-based CQIs: Data collection for

BCBSM/BCN, Medicare and Medicaid, and BCBSM/BCN, Medicare and Medicaid, and uninsured members (estimated 80% of data uninsured members (estimated 80% of data collection costs)collection costs)

Non-registry-based CQIs: a portion of staff Non-registry-based CQIs: a portion of staff resources for CQI-related processes resources for CQI-related processes

The CQI Coordinating CenterThe CQI Coordinating Center 19

CQI Incentive PaymentCQI Incentive Payment

Hospital CQIs: Hospital CQIs: Active participation and improved outcomes Active participation and improved outcomes

are rewarded through BCBSM’s incentive are rewarded through BCBSM’s incentive programprogram

Engaged physicians for select CQIs may Engaged physicians for select CQIs may receive a recognition payment through service receive a recognition payment through service codes beginning February 2013codes beginning February 2013

Professional CQIs:Professional CQIs: Active participation and improved outcomes as Active participation and improved outcomes as

reflected in the metrics through the Physician reflected in the metrics through the Physician Group Incentive Program Group Incentive Program

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CQI ParticipationCQI Participation

High levels of participation throughout MichiganHigh levels of participation throughout Michigan 95% of eligible hospitals participate in at least 95% of eligible hospitals participate in at least

one Hospital CQIone Hospital CQI 73% of hospitals participate in all of the 73% of hospitals participate in all of the

Hospital CQI programs for which they are Hospital CQI programs for which they are eligibleeligible

Over 329 physician practices participate in at Over 329 physician practices participate in at least one Professional CQIleast one Professional CQI

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Angioplasty CQI: OutcomesAngioplasty CQI: Outcomes

Between 2002 and Q3 2011, death has declined by 20%, contrast induced nephropathy Between 2002 and Q3 2011, death has declined by 20%, contrast induced nephropathy (CIN) by 38%, transfusions by 38%, vascular complications by 44%, emergency coronary (CIN) by 38%, transfusions by 38%, vascular complications by 44%, emergency coronary artery bypass grafting (CABG) by 92% and revascularizations by 17%artery bypass grafting (CABG) by 92% and revascularizations by 17%

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Hospital CQI SavingsHospital CQI Savings Over 2-3 years, 4 participating programs Over 2-3 years, 4 participating programs

produced $232.8 million in health care cost produced $232.8 million in health care cost savings savings

Complications and mortality rates lowered for Complications and mortality rates lowered for thousands of patientsthousands of patients Michigan Surgical Quality Collaborative (general surgery)Michigan Surgical Quality Collaborative (general surgery)

2009-2010: $ 85.9 million statewide savings; $49.2 million BCBSM savings2009-2010: $ 85.9 million statewide savings; $49.2 million BCBSM savings

Michigan Society of Thoracic and Cardiovascular Surgeons (cardiac surgery)Michigan Society of Thoracic and Cardiovascular Surgeons (cardiac surgery)2009-2010: $30.3 million statewide savings; $2.4 million BCBSM savings2009-2010: $30.3 million statewide savings; $2.4 million BCBSM savings

Michigan Cardiovascular Consortium - Percutaneous Coronary Intervention Michigan Cardiovascular Consortium - Percutaneous Coronary Intervention (angioplasty)(angioplasty)2008-2010: $102 million statewide savings; $13.8 million BCBSM savings2008-2010: $102 million statewide savings; $13.8 million BCBSM savings

Michigan Bariatric Surgery Collaborative (bariatric surgery)Michigan Bariatric Surgery Collaborative (bariatric surgery)2008-2010 : $14.6 million statewide savings; $4.7 million BCBSM savings2008-2010 : $14.6 million statewide savings; $4.7 million BCBSM savings

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Award Award Winning PartnershipsWinning Partnerships

Best of Blue Clinical Distinction AwardBest of Blue Clinical Distinction Award Michigan Surgical Quality Collaborative (2011)Michigan Surgical Quality Collaborative (2011) Michigan Bariatric Surgery Collaborative (2011)Michigan Bariatric Surgery Collaborative (2011) Quality Oncology Practice Initiative (2011)Quality Oncology Practice Initiative (2011) BMC2 – Percutaneous Coronary Intervention (2012)BMC2 – Percutaneous Coronary Intervention (2012) PGIP – “Fee for Value” (2012)PGIP – “Fee for Value” (2012)

Michigan Cancer Consortium Spirit of Collaboration Michigan Cancer Consortium Spirit of Collaboration Award (2011) Award (2011)

Quality Oncology Practice InitiativeQuality Oncology Practice Initiative Michigan Breast Oncology Quality InitiativeMichigan Breast Oncology Quality Initiative Michigan Oncology Clinical Treatment Pathways Michigan Oncology Clinical Treatment Pathways

Cancer Innovator Award (2011) Cancer Innovator Award (2011)

eValue8 Health Plan Innovation Award (2008) eValue8 Health Plan Innovation Award (2008) 24

CQI Model: Why It WorksCQI Model: Why It Works

Empowering the provider community to use comparative Empowering the provider community to use comparative effectiveness research in a collaborative contexteffectiveness research in a collaborative context

Measurement to inform is more powerful than Measurement to inform is more powerful than measurement to judge; BCBSM does not see individual measurement to judge; BCBSM does not see individual hospital datahospital data

Intrinsic motivation of professionals is harnessed when the Intrinsic motivation of professionals is harnessed when the work is owned and conducted by themwork is owned and conducted by them

Incentives focused on:Incentives focused on:

– Participation to help pay for the cost of data collection; and Participation to help pay for the cost of data collection; and

– Performance, to reward active and results-oriented participation Performance, to reward active and results-oriented participation catalyzes engagement and improved results.catalyzes engagement and improved results.

Focus on long-term transformation of care processes Focus on long-term transformation of care processes improves systems of careimproves systems of care

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Key TakeawaysKey Takeaways

CQIs support continuous quality improvement and development of best CQIs support continuous quality improvement and development of best practices for areas of care that are highly technical, rapidly-evolving, and practices for areas of care that are highly technical, rapidly-evolving, and associated with scientific uncertainty. associated with scientific uncertainty.

Collaborating across institutions accelerates improvement; more can be Collaborating across institutions accelerates improvement; more can be learned from variation in care processes and outcomes across groups learned from variation in care processes and outcomes across groups than within groups.than within groups.

CQIs target common clinical conditions and procedures associated with CQIs target common clinical conditions and procedures associated with high costs per episode. high costs per episode.

CQIs gather data on patient risk factors, processes and outcomes of CQIs gather data on patient risk factors, processes and outcomes of care. Use data to generate risk adjusted comparative performance care. Use data to generate risk adjusted comparative performance analyses and guide quality improvement interventions. analyses and guide quality improvement interventions.

CQIs help to further BCBSM's social mission of cultivating a healthier CQIs help to further BCBSM's social mission of cultivating a healthier future for all Michigan residents. future for all Michigan residents.

Patients, regardless of payer, benefit from improved care processes Patients, regardless of payer, benefit from improved care processes developed through an all-patient approach to practice transformation. developed through an all-patient approach to practice transformation. 26

The Future of CQIsThe Future of CQIs

Ongoing CQI and Overall Program Evaluation Ongoing CQI and Overall Program Evaluation including NIH-funded ROI analysisincluding NIH-funded ROI analysis

Michigan Spine Surgery Improvement Collaborative Michigan Spine Surgery Improvement Collaborative Aims: To improve the quality of care of spinal surgery by enhancing Aims: To improve the quality of care of spinal surgery by enhancing patient-reported outcomes following spine surgery; reduce surgical patient-reported outcomes following spine surgery; reduce surgical complications; reduce average costs of surgeries and episodes of care; complications; reduce average costs of surgeries and episodes of care; and reduce the rate of repeat spine surgeries.and reduce the rate of repeat spine surgeries.

Michigan Value Collaborative Michigan Value Collaborative Aims: To profile approximately 20 common inpatient conditions and Aims: To profile approximately 20 common inpatient conditions and procedures; to partner with existing CQIs to present findings and lead procedures; to partner with existing CQIs to present findings and lead discussions; and collaborate in designing and evaluating improvement discussions; and collaborate in designing and evaluating improvement interventions.interventions.

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Montefiore Medical CenterMontefiore Medical Center

Stephen Rosenthal, MBA, MSStephen Rosenthal, MBA, MS

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President and Chief Operating Officer at thePresident and Chief Operating Officer at theMontefiore Care Management Organization (CMO)Montefiore Care Management Organization (CMO)

Montefiore: More than a HospitalMontefiore: More than a Hospital

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Where We AreWhere We AreHigh-Cost, High-Volume EnvironmentHigh-Cost, High-Volume Environment

High Volume:High Volume: Over 90,000 admissions annuallyOver 90,000 admissions annually 3.5 million ambulatory care visits annually3.5 million ambulatory care visits annually 500,000 home care agency visits annually500,000 home care agency visits annually

Bronx, New York:Bronx, New York: 1.4 million people, 31% poor (vs. 21% across New 1.4 million people, 31% poor (vs. 21% across New

York) and 90% Hispanic and/or BlackYork) and 90% Hispanic and/or Black Higher prevalence of diabetes, obesity, asthma, Higher prevalence of diabetes, obesity, asthma,

other chronic conditions than New York City other chronic conditions than New York City 20% higher per capita medical expense than US20% higher per capita medical expense than US 8% of population 8% of population 50% medical expense 50% medical expense

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Our StructureOur Structure

Formed in 1995Formed in 1995 MD/ Hospital PartnershipMD/ Hospital Partnership Contracts with managed Contracts with managed

care organizations to care organizations to accept and manage riskaccept and manage risk

Over 2,400 physician Over 2,400 physician membersmembers– Over 500 PCPsOver 500 PCPs– Over 1,900 SpecialistsOver 1,900 Specialists

Established in 1996Established in 1996 Wholly-owned subsidiary of Wholly-owned subsidiary of

Montefiore Medical CenterMontefiore Medical Center Performs Performs care management care management

delegated by health plans, delegated by health plans, other administrative other administrative functions, (e.g. claims functions, (e.g. claims payment, credentialing)payment, credentialing)

Licensed Utilization Review Licensed Utilization Review agent and certified claims agent and certified claims adjustorsadjustors

Montefiore IPAIntegrated Provider Association

Montefiore IPAIntegrated Provider Association

CMOCare Management Company

CMOCare Management Company

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MIPA and CMO MIPA and CMO Cont.Cont.

Premium $Premium $

Insurance CompanyInsurance Company

CMOCMO MIPAMIPA

HospitalHospital

Savings

Specialty Care

Specialty Care

Primary Care

Primary Care

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How We Got Started How We Got Started Catalysts for InnovationCatalysts for Innovation

Reality of population Montefiore serves: low Reality of population Montefiore serves: low income, with chronic illnessesincome, with chronic illnesses

Early advent of managed care and the need for Early advent of managed care and the need for Montefiore to manage the premiumMontefiore to manage the premium

Significant competition among insurance Significant competition among insurance companies companies insurers saw partnering with us insurers saw partnering with us as opportunity to grow market shareas opportunity to grow market shareAlso substantial competition among provider groupsAlso substantial competition among provider groups

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How We Got StartedHow We Got StartedEarly QuestionsEarly Questions

Why Fill the Care Management Gap:Why Fill the Care Management Gap: Dominant presence in the BronxDominant presence in the Bronx Developed diverse set of primary care practices through Developed diverse set of primary care practices through

which to serve beneficiaries which to serve beneficiaries Improved relationships with providers in the communityImproved relationships with providers in the community

Decision Points:Decision Points: Determining the structure - combination of legal Determining the structure - combination of legal

parameters and financial considerationsparameters and financial considerations Seeking risk arrangements with payers vs. becoming a Seeking risk arrangements with payers vs. becoming a

payerpayer Focusing on particular care management and network Focusing on particular care management and network

support functions support functions Which payers to target initially and longer termWhich payers to target initially and longer term

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ImplementationImplementation

Worked with a few key partners:Worked with a few key partners: Collaborated with healthcare leaders to brainstormCollaborated with healthcare leaders to brainstorm Participated in National IPA coalition to learn about Participated in National IPA coalition to learn about

practices used across the countrypractices used across the country

Developed agreements with payers:Developed agreements with payers: First needed to understand their populationsFirst needed to understand their populations Getting the correct payment was criticalGetting the correct payment was critical Used a consistent model (full risk) Used a consistent model (full risk)

Getting up and running:Getting up and running: Cultivated a dedicated workforceCultivated a dedicated workforce Focused on transactional aspects of the business e.g. Focused on transactional aspects of the business e.g.

timely claims paymenttimely claims payment Understood the benefit packages and what employers Understood the benefit packages and what employers

expected of insurance companiesexpected of insurance companies At start, systems limitations were challengingAt start, systems limitations were challenging

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Our Current PortfolioOur Current Portfolio

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Initiative 2012 Population

2012 Est. Revenue

2013 Population

2013 Est. Revenue

Risk Contracts 140,000 $850 m 185,000 $1,085 m

Shared Risk 78,000 $490 m 80,000 $685 m

Medicaid Health Home (Care Coordination)

10,000 $10 m 10,000 $18 m

TOTAL 228,000 $1,350 m 270,000 $1,788 m

Strategic ApproachStrategic ApproachPopulation StratificationPopulation Stratification

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Care Guidance ModelCare Guidance Model

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OutcomesOutcomesPost-Discharge Call Program Post-Discharge Call Program

Readmission Rate Decreased 33% Readmission Rate Decreased 33%

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30-Day Readmission Rates

24.9%

21.5%

14.1%

0%

5%

10%

15%

20%

25%

30%

2008 Baseline (pre-program)

(n= 2,809)

2009-2010 High-Risk

Not Reached(n= 1,258)

2009-2010 High-Risk

Reached/ Assessed(n= 2,187)

At-risk patients defined as: age >69; having had a readmission in past 60 days; or having had home care services prior to admission

OutcomesOutcomesEffective Management of Diabetes Effective Management of Diabetes

12% Drop in Total Costs12% Drop in Total Costs

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Source: CMO Paid Claims; Author: H. Shao

Notes: Rx costs not available. Projected Costs Estimated using healthcare inflation trend of 16%

Key TakeawaysKey TakeawaysCare CoordinationCare Coordination

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Individual level:Individual level: Focus assessments on medical and psychosocial issuesFocus assessments on medical and psychosocial issues Expand capability to work with participants face to faceExpand capability to work with participants face to face Incorporate tools to support individual behavior changeIncorporate tools to support individual behavior change

Provider level:Provider level: Improve access and availabilityImprove access and availability Expand PCMH infrastructureExpand PCMH infrastructure Incorporate behavioral health expertise into care Incorporate behavioral health expertise into care

managementmanagement

System level:System level: Support organizational behaviors that reduce preventable Support organizational behaviors that reduce preventable

utilizationutilization Partner to identify vulnerable patients and create Partner to identify vulnerable patients and create

comprehensive care planscomprehensive care plans Develop IT infrastructure to support cross-organizational Develop IT infrastructure to support cross-organizational

communication and data exchangecommunication and data exchange

Key TakeawaysKey TakeawaysPromoting an Accountable Delivery SystemPromoting an Accountable Delivery System

Organizational governance, structure, Organizational governance, structure, alignment, and data are the foundationalignment, and data are the foundation

Must define and understand the populationMust define and understand the population <20% of the population determine the costs <20% of the population determine the costs

100% determine the quality of care100% determine the quality of care Sustainable cost reduction, improve Sustainable cost reduction, improve

performance and patient-centered care only performance and patient-centered care only with delivery system transformationwith delivery system transformation

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Key TakeawaysKey TakeawaysSetting the Stage for GrowthSetting the Stage for Growth

Use empirical evidence to support the spread Use empirical evidence to support the spread of your best practiceof your best practice

Develop or engage in forums for sharing Develop or engage in forums for sharing information (like AHRQ’s Innovation information (like AHRQ’s Innovation Exchange) to engage new champions Exchange) to engage new champions

Leverage technology to advance your Leverage technology to advance your success; need technology to move information success; need technology to move information to the right people at the right time and to to the right people at the right time and to enable staff to practice at the top of their enable staff to practice at the top of their licenselicense

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What’s Next?What’s Next?

New targeted interventions for select groups New targeted interventions for select groups Additional interventions for skilled nursing Additional interventions for skilled nursing

facility (SNF) residentsfacility (SNF) residents Expand linkage with community-based Expand linkage with community-based

providersproviders Expand strategies for beneficiary engagementExpand strategies for beneficiary engagement Focus on patient satisfaction (33 ACO quality Focus on patient satisfaction (33 ACO quality

measures)measures) Expand current programsExpand current programs

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RespondentRespondent

Xavier Sevilla, MD, MBA, FAAP Xavier Sevilla, MD, MBA, FAAP

Vice President for Clinical Quality

Catholic Health Initiatives, Denver, Colorado

Quality Health Policy Quality Health Policy BackgroundBackground

2000 To Err is Human: Call to improve 2000 To Err is Human: Call to improve the delivery system as a wholethe delivery system as a whole

2001 Crossing the Chasm: 6 Quality 2001 Crossing the Chasm: 6 Quality Dimensions, 10 Rules for Redesign of Dimensions, 10 Rules for Redesign of Health CareHealth Care

2007 Joint Principles of the Patient 2007 Joint Principles of the Patient Centered Medical HomeCentered Medical Home

2007 IHI Triple Aim 2007 IHI Triple Aim

Quality Health Policy Quality Health Policy BackgroundBackground

New approach to measuring quality: National New approach to measuring quality: National Quality Strategy April 2011 Quality Strategy April 2011

Better careBetter care Healthy communitiesHealthy communities More affordable careMore affordable care

ACO Medicare Shared Savings Program ACO Medicare Shared Savings Program 20122012

Current Landscape in Current Landscape in Health Care Policy/ QualityHealth Care Policy/ Quality

Using data to build a culture of quality: Using data to build a culture of quality: Slow improvement in quality (2.5% per Slow improvement in quality (2.5% per year)year)

Delivery system transformationDelivery system transformation Aligning payment policies with qualityAligning payment policies with quality Bending the cost curve: $2.7 trillion, Bending the cost curve: $2.7 trillion,

$1 out of every $6 in the economy$1 out of every $6 in the economy

Using Data to Build a Using Data to Build a Culture of QualityCulture of Quality

Pediatrix Medical GroupPediatrix Medical Group

Clinical Data WarehouseClinical Data Warehouse Automated data extraction from EHRAutomated data extraction from EHR Accessible and easy to use at the bedsideAccessible and easy to use at the bedside Extensive data validationExtensive data validation

Decreased clinical variation Decreased clinical variation Data down to individual clinicianData down to individual clinician Change culture to ongoing continuous quality Change culture to ongoing continuous quality

improvementimprovement

Delivery System Delivery System Transformation Transformation

HealthPartners in MinnesotaHealthPartners in Minnesota““Prepared practice teams interacting with Prepared practice teams interacting with informed, activated patients through informed, activated patients through continuous healing relationships supported by continuous healing relationships supported by ongoing availability of health information”ongoing availability of health information”Care Model Process (Delivery System)Care Model Process (Delivery System)

Team based careTeam based care Primary care based systemPrimary care based system Reliable, timely and actionable dataReliable, timely and actionable data Change of clinician’s cultureChange of clinician’s culture

Aligning Payment Policies Aligning Payment Policies with Quality Improvementwith Quality Improvement

Zero sum game between payers / Zero sum game between payers / providers: wrong kind of competition, providers: wrong kind of competition, shifting costs, increase bargaining power, shifting costs, increase bargaining power, restrict choicerestrict choice

Competition should be on creating valueCompetition should be on creating value Shift from pay for performance to pay for Shift from pay for performance to pay for

valuevalue

Status of Pay for Status of Pay for PerformancePerformance

Quality and Outcomes Framework Britain’s Quality and Outcomes Framework Britain’s National Health Service (2004)National Health Service (2004)““Overall only a modest improvement in Overall only a modest improvement in quality”quality”““Pay for performance had no discernible Pay for performance had no discernible effects on processes of care or on effects on processes of care or on hypertension related clinical outcomes” hypertension related clinical outcomes”

– BMJ 2011;342:d108BMJ 2011;342:d108

Alternative Quality ContractAlternative Quality ContractBCBS of MassachusettsBCBS of Massachusetts

Unique Contract Model: Accountability for Unique Contract Model: Accountability for quality and utilization, long term - 5 yearsquality and utilization, long term - 5 years

Controls Cost Growth: Global payment, Controls Cost Growth: Global payment, payment to adjust for inflation, incentive to payment to adjust for inflation, incentive to eliminate overuseeliminate overuse

Improved Quality and Outcomes: Bonus Improved Quality and Outcomes: Bonus payments up to 10% of the total contract, payments up to 10% of the total contract, used widely accepted quality measures, used widely accepted quality measures, outcome had more weight than process, outcome had more weight than process, frequent performance reports frequent performance reports

Bending the Cost CurveBending the Cost Curve

Bellin Health (Wisconsin): decreased health Bellin Health (Wisconsin): decreased health cost, health care costs below the national cost, health care costs below the national average for external employersaverage for external employers

Health knowledge of the population: health risk Health knowledge of the population: health risk assessments for all patientsassessments for all patients

Care management for at risk patientsCare management for at risk patients Integrated system of care coordination: nurse Integrated system of care coordination: nurse

call line entry point, primary carecall line entry point, primary care Created a culture of health Created a culture of health

ConclusionsConclusions

Reform of the health care system is not Reform of the health care system is not only possible, but is flourishing in a only possible, but is flourishing in a number organizations such as number organizations such as Montefiore and BCBS MichiganMontefiore and BCBS Michigan

Visionary leaders are not waiting to see Visionary leaders are not waiting to see what the new healthcare environment what the new healthcare environment will look like but are innovating to will look like but are innovating to improve their organizations today and improve their organizations today and position them for the futureposition them for the future

The Future of Health Care The Future of Health Care Policy InnovationsPolicy Innovations

Partnerships and collaboration Partnerships and collaboration

The new roles for patientsThe new roles for patients

Sick care versus wellness Sick care versus wellness

Health versus healthcareHealth versus healthcare

Question and AnswerQuestion and Answer

Click on “Ask a Question” below this Click on “Ask a Question” below this presentation. Complete the form and click presentation. Complete the form and click “Submit.” “Submit.”

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