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MICAH Quality Network

Population Insights Reporting and 2017‐2018 PG5 P4P Program Year Updates

Blue Cross Blue Shield of MichiganHospital Incentive ProgramsAugust 18th, 2017

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Topics for Today’s Discussion

Review Population Health Insights Report

Wexford/Crawford PHO Presentation

Review 2017‐2018 Scoring Thresholds

Financial Impact of P4P Program

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BCBSM – Peer Group 5 P4P Program

REVIEW: Population Insights Reporting

Blue Cross Blue Shield of MichiganHospital Incentive ProgramsAugust 18th, 2017

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Key Takeaway: Population Insights reports reveal the natural relationships between PCPs and hospitals who receive incentives for providing care for the same groups of BCBSM members

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BCBSM’s Population Insights Reports – Overview

Semi‐annual reports that develop and display meaningful, volume driven relationships between:1) PGIP‐participating Primary Care Physicians (PCPs) and 2) acute care hospitals

SubPO A

SubPO C

SubPO X

BCBSM Members

PGIP‐participatingPrimary Care Physicians Michigan Acute 

Care Hospitals

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Key Takeaway: 

Population‐based performance for hospitals includes costs and utilization for all BCBSM members 

attributed to their partners; not limited to those services within 4‐walls

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Creating population‐based cost and utilization metrics

Hospital‐level, population‐based metrics are created using a weighted average between:1) Physician Organization performance and 2) % of hospital business from those groups

SubPO A

SubPO C

SubPO X

PGIP‐participatingPrimary Care Physicians

SubPO A cost and use metrics:

• $300 PMPM

• 200 ED visits/1,000

• 100 IP admissions/1,000

SubPO C cost and use metrics:

• $250 PMPM

• 250 ED visits/1,000

• 75 IP admissions/1,000

SubPO X cost and use metrics:

• $225 PMPM

• 150 ED visits/1,000

• 50 IP admissions/1,000

Hospital ABC population‐based 

cost and use metrics:

• $285 PMPM

• 202.5 ED visits/1,000

• 91.25 IP admissions/1,000

75% of Hospital Business

15% of Hospital Business

10% of Hospital Business

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1) Understanding who your Physician Organization partners are:

PGIP‐participating PO and SubPOgroups with a shared patient populationwith the hospital

Drop‐down menu to select hospital of choice

Number of PCPs participating in PGIP with these PO/SubPO groups

Total count of BCBSM members “attributed” to PCPs in this group

Average # of BCBSM       members per PCP in this group

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2) Strength of volume‐driven relationships with physician partners:

PGIP‐participating PO and SubPOgroups with a shared patient populationwith the hospital

Number of BCBSM members requiring hospital‐based services in given measurement year (n, %)

Total count of BCBSM members “attributed” to PCPs in this group

Proportion of hospital‐utilizing members who chose to seek care 

at YOUR hospital (n, %)

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3) How your hospital’s population‐based metrics are calculated:

From the hospital’s perspective:proportion of BCBSM members who 1) walk through hospital’s doors2) have a care relationship with a PGIP PCP 

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4) Reviewing your hospital’s population‐based cost metrics:

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5) Reviewing your hospital’s population‐based utilization metrics:

Other metrics include:

1. Overall and ambulatory care sensitive inpatient (IP) admissions per 1,000

2. 30‐Day All Cause and Unplanned Readmission Rates

3. Generic pharmacy prescribing (%)

J a c q u e R u n y o n R N , B S N , M S A

Tr a n s i t i o n s o f C a r e P r o j e c t L e a d

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B e t h O b e r h a u s R N , B S N , M B A, P M P

C l i n i c a l O p e r a t i o n s D i r e c t o r

Community Based Population Health

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Physician Hospital Organization (PHO) overview

A PHO is a vehicle that enables hospitals and physicians to work cooperatively towards accomplishing goals that benefit the patients in the community.

A PHO is a legal entity which allows for clinical integration and joint contracting.

The goal of the Wexford PHO is to keep health care local by focusing on the needs of the community with broad physician input and leadership

The mission of the Wexford PHO is to support its members and hospital in the provision of quality health care that is efficient, promotes access and improves the health of people in our community

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PHO Services

Member Services Networking and

collaboration

Payer contract enrollment

Provider relations support

Education and training CME

HIPAA 5010

ICD-10

Meaningful Use

Contracting Services

Clinical Integration Process Improvement

Payer program support

Registry – Wellcentive

PCMH/PCMN Support

Care Management

Patient Satisfaction –Michigan Experience of Care (MiPEC)

Community linkages

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A patient-centered medical home is not a building, house, hospital or home healthcare service, but rather an approach to providing comprehensive primary care.

In the patient-centered medical home the care team works in partnership with the patient and at times patient’s family to assure that all of the medical and non-medical needs of the patient are met.

Key Components: Cost Savings, Efficiency, and Patient Satisfaction

What is a PCMH?

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“Principles” of the Patient-Centered Medical Home

• A personal physician who coordinates all care for patients and leads the team.

• Physician-directed medical practice – a coordinated team of professionals who work together to care for patients.

• Whole person orientation – this approach is key to providing comprehensive care.

• Coordinated care that incorporates all components of the complex health care system.

• Quality and safety - medical practices voluntarily engage in quality improvement activities to ensure patient safety is always being met.

• Payment – a system of reimbursement reflective of the true value of coordinated care and innovation

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Capabilities

Patient Provider Partnership Patient Registry Performance Reporting Individual Care Management Extended Access Test Results Tracking and Follow up Preventive Services Linkage to Community Services Self-Management Support Patient Web Portal Coordination of Care Specialists Pre-Consultation and Referral Process

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We are all in this together

Accountable Care Organization (CMS)

Organized System of Care (BSBSM)

Accountable Care Network (Priority Health)

Clinical Integrated Networks (Super PHO’s)

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How are we measured

HEDISThe Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. Altogether, HEDIS consists of 81 measures across 5 domains of care.

Health Plans (Measured and PAID) Diabetes

Asthma

Hypertension

Mental Health

Prevention

Cost and Utilization

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Measured together

Most cost and quality measured are paid out at the PHO level based on our whole population of patients.

We are accountable for the cost of the hospital stay and the quality of the stay even if they go to a hospital outside of our community.

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Yearly review of Population Insight Reports

Where are our patients going (within our partner hospitals?)

Have we decreased the number of patients utilizing hospitals from year to year.

Are our partner hospitals High cost?

Are we impacting Primary Care Sensitive ED visits?

Are we Impacting Ambulatory Care Sensitive Admissions?

How about readmission rates?

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Score card

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Score Card Continued

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How do we determine success

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PCMH is the start

12 years ago PCMH started PCP to SCP referral processes improved Communication between provider increased Decrease of duplicate testing, increase patients

confidence when provider talk We have not perfected this, but now everyone

agrees it is important Need improved IT capabilities to really succeed.

(HIPAA complaint texting, telemedicine, payment to support improve communication), ect.

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Care Management

Care Management added a needed layer to proactive management of patients.

We can not wait until patients are sick to engage them and be successful in the triple aim (sick patients are expensive)

Education, self management skills and connection to community resources are all key in improving cost, quality and patient satisfaction.

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Care Management Case Study-Ms. W

50 y/o Female

Type 2 DM, HF and Depression (main concerns)

Also-hypertension, hyperlipidemia, Degenerative Disc Disease, lumbosacral radiculopathy and anxiety

In May BMI of 39.3

A1C was 14.0

Wexford/Crawford PHO

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Care Management Activities

Initial assessment

Phone calls and Face to Face visits

Established Trusting Relationship Express Frustrations

Identify barriers

Patient Set Goals “get out and move” 10minutes a day, 4 days of the week

bowl in a league again

Wexford/Crawford PHO

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Success One Patient at a Time

Ms. W 5 months later more engaged in the management of her chronic health conditions. A1C was 8.3

lost 28lbs

not missed a scheduled appointment since the onset of care management

She stated that she “finally feels empowered and encouraged to take the help that is being offered and use it.”

Wexford/Crawford PHO

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Wrap up

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Transitions of care

Some time the hospital goals and the PCP goal don’t line up!

Care managers we quickly full and managing other needs. Hospital re-admission didn’t decrease as much as we had hoped.

SO, we added a liaison between hospital case management and ambulatory primary care and specialists.

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Cadillac Hospital/Wexford PHO partnership

Transitional Care Manager

Focused on readmission rates

Part of Ambulatory Care management team (embedded into PCP practice just like care managers)

Manages top 6 diagnosis (COPD, Stroke, MI, Pneumonia, Orthopedic Surgery and DM)

Manages 30 days in partnership with Care manager, home care, SNF, etc...

Pre-hab for high risk surgical patients next step in the journey

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The good the bad and the ugly

Congestive Heart Failure

Enhanced Recovery

COPD

Diabetes

Behavioral Health

Pharmacy

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Process Barriers

Chronic Disease Lack of Care Managers to reinforce education Lack of Palliative Care Services Lack of standard process, communication and education materials.

Change across dispirit organizations is challenging.

Patient engagement Provider engagement Cost of change Team Dynamics Lack of change management skills Lack of PCP’s in community

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Process Success

Physician Leadership

Senior Leadership Commitment (PHO and Hospital)

Community engagement

Payer Funding

Role acceptance (PHO, Hospital and Community)

Appetite for change

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Time to think outside the Box

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Future

Payment reform is “Purposely Disruptive”

Advanced Payment Models (Risk based payment) CPC+

Bundled Payments

MACRA/MIPS

Risk based contracts

SIM-Community Health Workers

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Crossing the CrevasseVALUE BASED PAYMENT

Brave new worldNew business model – Focus on populations and episodes of carePrimary care becomes keyProfits from higher quality care in home settingLongitudinal payments for chronic careBundled payment Joint contracts with payersFocus on data

Need to Excel at FFS While Building for Value Based Payment

Clinical Integration is a way for physicians and health systems to bridgethe gap between FFS reimbursement world and tomorrow’s (today’s) value based payment world

FEE FOR SERVICE

•A business we know and love (and have thrived at)  •It’s all about volume•Maximize price to commercial payers to offset losses on government business•Focus on specialists

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Thank you for improving health care for the people of Michigan