7/7/17. Value and Quality in Health Care. Kevin Shah, MD MBA. Overview of Quality. Define. Measure. Improve

Transcription

1 Value and Quality in Health Care Kevin Shah, MD MBA 1 Overview of Quality Define Measure 2 1

2 Define Health care reform is transitioning financing from volume to value based reimbursement Today Fee for service Future Value / Risk based reimbursement Care for individuals Manage populations Specialty care focus Primary care focus How do you measure value and quality? 3 3 Define A simple framework to approach health care quality Outcomes Metrics Is the patient healthier? Live longer Live healthier d clinical metrics Avoid adverse events Process Metrics Was the correct care provided? Appropriate Care Timely care Avoid unnecessary care Avoid errors Patient Experience How was the patient s experience? Adequate communication Easy access to care Patient felt needs were met Cost Was the care cost effective? Cost to patient / payer Cost relative to appropriate benchmark Avoidance of future cost 4 2

3 Define Various entities weigh parameters differently in defining quality Patient Outcomes Process Pt Experience Cost ++ x + + Providers xx Payers x ++ Employers Illustrative only Various private and government entities are designing and implementing quality programs with varying areas of focus 5 Define There are a variety of programs that measure quality and value Government - Value Based Purchasing - Hospital Readmissions Reduction Program - Hospital Acquired Conditions Program - Medicare Advantage: STAR ratings - Medicare ACOs - Hospice Quality Initiative - Physician Quality Reporting System PQRS) - State CABG reporting systems - Many others Private Insurers: - ACO plans - Narrow network / high performing network plans - Many others - Choosing Wisely Providers - Internal quality benchmarking for QI and compensation - Transparency of patients satisfaction and outcomes - Choosing Wisely Patients are increasingly having access to this quality reporting 6 3

4 Measure Define Measure: Evaluate several case studies 7 Case Studies Examples to study - CMS: Hospital Value based purchasing - Commercial Payer: adequate clinical care. - Health System: Patient Satisfaction 8 4

5 Case Studies: CMS CMS s Hospital Value Based Purchasing (VBP) - Legislatively endorsed by the Patient Protection and Affordable Care Act (PPACA, i.e. Obamacare) FFS Payments: X% OLD SYSTEM FFS Payments: 100% VBP Payments: (1-X) % - Budget neutral: there are winners and losers - Withholding: FY % à FY % 9 Case Studies: CMS Medicare Value Based Purchasing metrics have evolved over time Value Based Quality Metrics Number Outcomes Process* Pt Experience Cost 2013 None 12 8 None None

6 Case Studies: CMS Value Based Purchasing FY2016 Metrics 11 Case Studies: CMS Value Based Purchasing FY2016 Metrics (cont) 12 6

7 Case Studies: CMS Weightings for VBP have shifted towards outcomes and cost Value Based Quality Metrics % Outcomes Process Pt Experience Efficiency 2013 None 70% 30% None % 45% 30% None % 20% 20% 30% % 10% 25% 25% Through VBP, most hospitals in the United States have a portion of their reimbursement contingent on cost and outcomes 13 Case Studies: CMS CMS calculates a Total Performance Score that adjust payments Clinical X Domain Weight = Clinical weighted Score + Patient Experience X Domain Weight = Patient Experience Weighted Score + Outcomes X Domain Weight = Outcomes Weighted Score + Efficiency X Domain Weight = Efficiency Weighted Score New domains will be calculated for FY17 Total Performance Score 14 7

8 Case Studies: CMS HospitalCompare.gov gives patients quality comparisons of hospitals Patient Experience Clinical process Readmission and complications Payment and Value of care HospitalCompare.gov is focused on Medicare data only, This website does not offer any physician specific data 15 Measure: Examples to study - CMS: Hospital Value based purchasing - Commercial Payer: adequate clinical care. - Health System: Patient Satisfaction 16 8

9 Case Study: Commercial Payer Private Payer: Evaluate appropriate disease screening Select chlamydia screening: an important evidence based screening guideline. From NCQA: The percentage of women years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year. How does a payer define sexually active via its data? 17 Case Study: Commercial Payer Private payers often use billing and claims data for quality measurement NCQA language on chlamydia screening - Two methods identify sexually active women: pharmacy data and claim/encounter data. The organization must use both methods to identify the eligible population; however, a member only needs to be identified in one method to be eligible for the measure. What are the implications of this in clinical practice? 18 9

10 Measure: Examples to study - CMS: Hospital Value based purchasing - Commercial Payer: adequate clinical care. - Health System: Patient Satisfaction 19 Case Study: Patient Satisfaction In 2009, University of Utah began publishing patient satisfaction scores on all providers 20 10

11 Case Study: Patient Satisfaction Univ of Utah also releases patient comments on providers - Pre 2009: 4% of providers Univ of Utah in top 10% of Press Gainey survey. By 2013 the number had increased to 46% - Powerful tool for transparency and patient marketing - Incentive for provider behavior change 21 Case Study: Patient Satisfaction Duke Health began providing similar ratings in 2016 Numerous health systems now following this path including: - Duke - Clevland Clinic - Univ of Pittsburgh - Stanford - Many others At Duke, various measures of patient satisfaction are linked to health system quality dashboards 22 11

12 Overview of Quality Define Measure : The Duke Primary Care Experience 23 Translating science into clinical practice is challenging Scientific knowledge Basic science Clinical Research Regulatory approval Medical community consensus Implementation Challenge Variable uptake of new research and practice guidelines Limited infrastructure for implementation science varied across the country How to fix this? 24 12

13 7/7/17 An overview of Duke Primary Care Demographics - 34 clinics including continuity and urgent care providers including FP, IM, Peds - 700K visits in the last fiscal year Provider Compensation: - Base Salary - Productivity Bonus - Quality Bonus based upon - 3 quality metrics (varies by provider type) - Patient Satisfaction 25 Duke Primary Care has developed a quality improvement infrastructure ment team Director of Performance Excellence Physician and nurse champions at clinics Practice level coaching and mentoring Leadership training Administration Clinic leadership Value based financial incentives Quality Patient satisfaction Data transparency Visibility boards in clinics Monthly dashboard and quality reporting 26 13

14 What does Lean healthcare look like? A focus on understanding current state: data and process A focus on target state Go see where the work is done Involve the people who do the work Leadership model that supports improvement work PDSA and Rapid improvement events - Involve all stakeholders in problem solving - Pilot workflow and care delivery in one or two clinics - Refine best practices are then spread 27 Numerous health care organizations are leveraging quality improvement science Virginia Mason Medical Center - Virginia Mason Institute: Lean Healthcare solutions ThedaCare - ThedaCare Center for Health Care Value Intermountain Health - Intermountain Institute for Health Care Leadership. Duke University Health System - Redesigning inpatient care into codified care bundles - Improving care for patients who are Familiar faces by redesigning the outpatient care team - Transforming Primary Care Collaborative 28 14

15 A Duke Primary Care Example: Improving Care for Diabetic Patients Defining the problem Measure current performance care - Engage and incentivize providers - Engage front line staff 29 Duke Primary Care defined a composite diabetes quality metric Diabetes composite A1c BP Statin therapy Antiplatelet therapy Smoking status Engaged providers on defining what is optimal care for diabetics, and what the targets should be Relevant to patient health and outcomes Aligned with payer sponsored quality metrics 30 15

16 Defining all of the elements for this quality metric is challenging - How does one define a diabetic? - What patients do one include or exclude? - How many months / years back should this go? - What is the A1c goal? - What BP goals? Should they vary by age? - Should all diabetics be on aspirin and / or statin? - Should providers get credit for medication allergies - Should a provider receive credit for tobacco cessation counseling - What does it mean to meet the metric? Many others!!!! 31 Final definition for the diabetes metric % of a provider s patients who are in the Diabetes registry AND who have the DPC provider listed in the Maestro PCP field AND who have a visit anywhere in the Duke system within the reporting period who meet all 5 of the following criteria: - A1c <8.0 - BP < 140/90 (<150/90 for age >60) - On a statin OR have a documented allergy in the allergy list to statin OR are <40 y/o - On anti-platelet therapy OR have a documented allergy in the allergy list to aspirin OR <40 y/o OR 10 yr ASCVD <10% OR On Anticoagulation - Non-smoking status Target: 25% Page

17 RIE demonstrated substantial gaps in use of ancillary services Analyzed how several clinics take care of patients with diabetes. Physicians were significantly involved in care but What the rapid improvement event accomplished Data: Progress bulletin boards in clinics Rooming staff: CMAs performing diabetic foot exams Standardize intake documentation around diabetic meds and diet Automatic referral to DM education for uncontrolled diabetics Nurses New population health nurse Outreach calls to diabetics Provider Resources CME Embedded diabetic education at some select practices E Consults to endocrinology Smoking cessation clinics 34 17

18 Over the last year, providers have made improvement DPC Total FY2016 DPC Total FY % 90.0% 80.0% 70.0% 73.1% 70.0% 80.3% 79.7% 77.0% 72.1% 88.1% 89.1% 62.2% 82.9% 60.0% 50.0% 40.0% 36.8% 30.0% 26.5% 20.0% 10.0% 0.0% 35 A1C % Met BP % Met Statin % Met Smoke % Met AP % Met All 5% Met Conclusions - Define, Measure, - Quality and value can be approached systematically - Quality metrics are pervasive in numerous clinical and insurance models - Paying for quality can be an important component of a broader quality strategy - Quality improvement methodologies can markedly improve the delivery of health care services 36 18

19 Interesting thought questions - Are we measuring the right thing? - Is Value or Quality creating dangerous incentives? - What type of people and skills are needed to manage this? - What is the next generation of value and quality? 37 19