Employment of Data Transparency and Analytics as a Strategy to Enhance Provider Collaboration and Engagement

Transcription

1 Employment of Data Transparency and Analytics as a Strategy to Enhance Provider Collaboration and Engagement Mark Piasio, MD, MBA Medical Director, Network Reimbursement Strategy and Informatics Highmark, Inc Highmark Inc. All rights reserved. Highmark Inc Highmark Health Services Largest health insurer in Pennsylvania Based in Pittsburgh with offices throughout the USA 20,000+ employees, with 11,000 in PA 5.3 million members nationally Serves 33.5 mil customers nationwide in health, dental, vision, and supplemental health products Allegheny Health Network Third largest IDN in US Employs an additional 17,

2 In the medical market, we re already in the new world The next five years in the medical market won t see huge changes per se but they might feel like huge changes Trends that are already happening will expand and consolidate. Primary care changing: teams, PCMH, coordinated ambulatory and acute Greater access points, alternative delivery models and alternative practitioners Pay for Value incentives, including in specialty care Early ACO and gain share Transparent unit pricing More rigorous credentialing by payers, hospitals, societies and state boards Aggressive consumerism, transparency and accountability Growth in HDHP s Smaller selective networks Expanded Medicaid and private individual insurance plans/members 3 CMS Driving Change MSSP Bundled Payment Care Improvement Program Readmissions Penalties No pay conditions/hac ACO s HCC QRS for QHP STARS 4 2

3 We must evolve to survive a changing environment 5 Shifting from Volume to Value Patient-Centered Medical Home programs around the nation are already showing ROI and creating real savings Patient outcomes and experience must be optimal Quality Blue Patient Centered Medical Home (PCMH) begins the transformation Focus on population management Leverage information and technology First step in the inevitable move from fee-for-service to pay-for-value 6 3

4 Emerging Care Delivery Strategies Payment and network strategies are being utilized in tandem to align incentives with high quality and coordination across providers Quality High Patient-Centered Medical Home (PCMH) Accountable Care Model (ACO) Reward for Value Total Cost A model of Pay-for- care where each patient A group of healthcare providers who of Care has an Performance ongoing relationship with agree to manage and accept a primary care physician (PCP) Episodebased patient population and whose accountability for all care of a who coordinates APR-DRG a team/ that RBRVS / Payment takes collective responsibility primary focus is to improve the APG / EAPG for patient care and, when overall health of its patients while appropriate, arranges for care with managing the total cost of care other qualified physicians and improving patient experience Fee-for-Service Capitation Low Low Align Incentives / Bundle Services High Coordination 7 Benefits of Transformation Source: Patient-Centered Primary Care Collaborative, Benefits of Implementing the Primary Care Medical Home: A Review of Cost & Quality Results,

5 Benefits of Transformation Source: Patient-Centered Primary Care Collaborative, Benefits of Implementing the Primary Care Medical Home: A Review of Cost & Quality Results, Benefits of Transformation Source: Patient-Centered Primary Care Collaborative, Benefits of Implementing the Primary Care Medical Home: A Review of Cost & Quality Results,

6 Highmark s Overall Strategy Highmark Goal: Move 75% of Highmark membership to pay for value programs over the next 3 to 5 years 11 HIGHMARK CARE MODEL PROGRAMS Risk sharing Accountable Care Organization Pay-for-value Outcome based gain sharing ACO Specialist Episodic Performance Metric based bonus PCMH PCMH Pay-forperformance P4P Quality Blue Non-financial incentives Physician Assessment Cardiology Physician Performance Assessment Highmark builds on its quality and affordability programs to introduce the Quality Blue Patient Centered Medical Home (PCMH) to create an innovative and tailored model for providers 12 6

7 Quality Blue Accountable Care Alliance (ACA) The Triple Aim Connect Independent Providers Performance Measurement Information Sharing Integrate Technology, People & Process Gain-Share / Risk-Share 13 Highmark Commitment to Data Transparency We believe transparency is a business philosophy where information is communicated openly and clearly to our customers, providers and the public. Being transparent helps a company to establish a reputation of trust because people feel they have been accurately informed. By leveraging information and technology, Highmark will work with partner providers to increase transparency between members, health plan, and doctors, using data and reporting that may: Increase the quality of care Improve the patient experience Reduce the total cost of patient care through population management Having a better understanding of health care costs will allow one to make choices that help to keep the cost of health care in check, thus bending the care cost curve. 14 7

8 ACA/PCMH Performance Measurement Overview Network ACA/PCMH Program Improved Data Transparency & Provider Tools Quarterly Quality dashboards Quarterly PMPM actual and target reports Quarterly Cost & Utilization dashboards Quarterly Care Alignment reports Transformation plan (Milestone Document) Transformation education curriculum Transformation Tool Provider Intelligence (PI) Tool Provider Intelligence Tool Population management tool Stratify by practice, provider, member level Identifies high risk populations Identifies patient quality gaps Provides insight into costs across the continuum Acute inpatient, outpatient, pharmacy, specialty care, etc. Customized reports making easy for provider to identify opportunities Queries/reports can be used for patient preparation work lists 8

9 Quality Dashboard Group Bucket Measure Description Numerato r Denomin ator Complianc Benchmar e k Type Projected 4 Star Met/ Exceeded Pass Prevention Scored QN08 Breast Cancer Screening % 71.00% Highmark 74.00% Y QN09 Colorectal Cancer Screening % 56.00% NCQA 58.00% Y QN10 Cervical Cancer Screening % 74.00% NCQA. Y Pediatric and Adult Well Care Scored QN01 Appropriate treatment for children with URI % 89.00% Highmark Appropriate Testing for Children with QN % 91.00% Highmark NS Pharyngitis. QN05 Adolescent Well-Care Visits % 48.00% Highmark. Y Well-Child Visits in the First 15 QN12_ % 84.00% Highmark NS Months of Life: Six or more visits.. NS QN13 Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life % 76.00% Highmark. N QN17_1 Adults' Access to Preventive/Ambulatory Health Services: 65 Years and Older % 99.00% Highmark. Y QN17_2 Adults' Access to Preventive/Ambulatory Health Services: Years % % Highmark. Y QN17_3 Adults' Access to Preventive/Ambulatory Health Services: Years % % Highmark. Y QN20 Childhood Immunization Status: MMR Vaccination % 90.00% NCQA. NS QN21 Childhood Immunization Status: Varicella (VZV) Vaccination % 90.00% NCQA. NS 17 Cost and Utilization Scoring Threshold PMPM is set by projecting base PMPM at regional market trends less expected Program savings Full Savings PMPM is set by projecting the lower of: 1) the regional Highmark network market trend less expected Program savings or 2) CPI based target trends established by the Participants PMPM tier (see table below) Points are awarded based on where Actual PMPM falls between the two trends (weighted for current membership) The benchmarks will be fixed for a two year period (with the market trend measured retroactively) Results will be reported quarterly and scored twice per year Entities with fewer than 2,500 attributed members will be aggregated due to volatility and credibility concerns TIER Threshold Full Savings Highest PMPMs Market - 2% Min (Market-5%, CPI - 1%) Average PMPMs Market - 1% Min (Market - 4%, CPI - 0%) Lowest PMPMs Market - 0% Min (Market - 3%, CPI + 1%) 18 9

10 PMPM Assessment Exceeding Trend Current Experience Projected Base Period Projected Benchmark Period 7/1/2012 6/30/2013 1/1/ /31/2013 1/1/ /31/2014 Category Average Actual Base Period Threshold Market PMPM Members Experience PMPM PMPM Full Savings PMPM Children 6,890 $ $ $ $ $ Adults 14,170 $ $ $ $ $ Medicare Advantage 1,039 $1, $1, $1, $1, $1, Composite 22,098 $ $ $ $ $ Partnering to Bend the Cost Curve Providing total cost data has facilitated increased physician engagement Education takes time, but doing so enhances relationships Very focused on cost drivers, market comparisons and risk scores Providing market risk score comparison data levels playing field Providing both entity & practice level data heighten awareness to variability in care Data begets data; Peeling back layers of the onion April 1, March 31, 2014 Commercial Adult Avg Attrib Members Avg Member Risk Member Months Mkt Member Risk 8, Utilization / 1000 PMPM Curr Trend Mkt Trend Curr Trend Mkt Trend Facility Inpatient Medical % 37.5 (0.5%) $ % $ % Surgical % % % % Maternity 8.1 (67.8%) 11.2 (2.9%) 3.34 (56.3%) % Psych / Substance Abuse % % % % SNF / Rehab % % Subtotal % % $ % $ % Facility Outpatient Emergency Room (12.2%) (1.7%) $ % $ % Surgery - Hosp Outpatient (33.3%) % (37.9%) % Surgery - ASC 24.3 (42.7%) 62.4 (2.7%) 2.44 (40.8%) % Psych / Substance Abuse 37.8 (68.3%) % % % Radiology % (0.1%) % % Pathology / (8.2%) 1, % 3.01 (23.8%) % Pharmacy 93.2 (7.5%) (0.9%) % % Other (26.9%) 2, % (41.2%) % Subtotal 1,882.2 (19.8%) 4, % $ (8.2%) $ % 10

11 Population Management: PI Tool Data technology and analytics that assist participants in meeting the goals of the ACA PCMH program Benefits of tool: Data are refreshed monthly and more current than program dashboards Stratify by practice, provider, member level Identifies high risk populations Identifies patient quality gaps Provides insight into risks, costs, and performance across the continuum Acute inpatient, outpatient, pharmacy, specialty care, etc. Customized reports make it easy for provider to identify opportunities Queries/reports can be used for patient preparation work lists (pre-visit prep and planning) Capability for aggregate and individual member reporting Provider Intelligence (PI) Tool: Powerful Analytics Highmark makes available the Verisk Provider Intelligence Tool Capable of synthesizing a wide range of patient data Report Name Clinic Manager Report Physician Manager Report Utilization Metrics Report Individuals Report PCMH Report Top 25 by Risk Severity Score Disease Registry Report Quality Risk Measures (QRM) Report Data Provided Practice level performance against various efficiency and quality metrics Physician level performance against various efficiency and quality metrics (same information as Clinic Manager Report, but specific to individual physicians) Practice or physician level performance against various efficiency and cost metrics A list of individual patients attributed to a physician or practice and their specific efficiency and quality performance data Population s performance against Highmark s ACA/PCMH quality dashboard measures A list of the top 25 highest risk patients, who are predicated to need significant medical resources, for a physician or practice A list of diseases that affect the members attributed to the particular practice or physician, the number of patients affected, and specific cost and utilization performance data Population s performance on Verisk Health s quality and risk measures for a selected practice or physician 22 11

12 POPULATION SUMMARY REPORT 23 Key Challenges to Sharing PI Tool Data Ensuring vehicles for data delivery meet privacy & security standards; address early in planning phase Access issues related to sharing the tool through Highmark s provider portal; involve all parties in deployment plan and issues resolution Tool is quite large and may be overwhelming at first; start with one or two top reports Time restrictions; convince practice users to incorporate the tool into process flow by showing efficiencies gained or potential impact to program scoring, e.g., pre-visit planning, high risk patients, utilization metrics 12

13 Key Challenges, Continued Many practices do not have the resources to mine the data and translate to information for decision making or the resources are not savvy in data analysis and/or data manipulation; provide education and have support available PI Tool is not an exact match to Quality Blue PCMH/ACA program data; provide detail on differences noted in reporting Provider number and practice structural changes affect attribution methodology; inform providers how long it will take to see this reflected in the tool Mechanism to accept support documentation from providers; create a feedback loop Quality Blue ACA Care Alignment Support Reporting Provider Care Coordination and Alignment Patterns This report enables the review of specialist care patterns in total and for an ACA attributed population of members. Page 1 All Highmark Members Page 2 ONLY ACA Attributed Members 26 13

14 Other Resources Clinical Transformation Consultants (CTCs) Medical Directors Informatics and Analytics staff Pharmacy consultants Provider Relations Entity Level Opportunities in Quality and Cost Quality Total Quality Score (max 50) ENTITY 41 Opportunity #1 Appropriate treatment for children with URI Opportunity #2 Childhood Immunizatio n Status: Varicella (VZV) Opportunity Opportunity Opportunity #3 #4 #5 Use of Spirometry Testing in the Assessment & Diagnosis of COPD Fall Risk Plan of Care for Older Adults Annual Wellness and Initial Preventative Physical Exam Rate (PROFILED) Cost ENTITY Opportunity Opportunit #1 y #2 OP MRI for peds Prosthesis for Comm Adult Opportunity #3 IP MRI for Comm Adult and Peds Opportunity #4 Facility inpatient Psych/Substance abuse both peds. and MA populations. Opportunity #5 Inpatient extended care visits 28 14

15 Pre-Engagement Assessment Scoring Tool Highlights 34 Scored Questions 7 Subjective Questions that are informational only Four areas of focus Patient Follow-up Scheduling of AWV etc. After Hours Appointments Chart Prep Measurement on Improvement Gap Closure Process 33 Points PCMH Designation Data analysis Development of action plans Proactive Engagement with member s Culture of Quality 14 Points Electronic Medial Record Meaningful Use Software Utilization Competency Web Ex Participation Technology 8 Points Participation in Meetings Assigned Physician Champion Sufficient Staffing People & Personnel 5 Highmark Inc All rights reserved.this i f ti i fid ti l t 29 Engagement Assessment Tool Tool Highlights 27 Scored Questions 1 Questions scored based on performance outcomes Engagement and Transformation Sections are broken into difference Categories Education session participation Use of Highmark Tools Implementation of action plans Meeting Attendance Engagement 21 Points PCMH Meaningful Use Team based care Extended access hours Evidence-based practice Disease registries Population Management Transformation 20 Points Outcomes based upon practice s performance measurement Performance Outcomes 3 Points Pre-visit Highmark Inc All rights reserved.this i f ti i fid ti l t 30 15

16 Engagement Assessment Reporting Results are pulled into weekly reports that demonstrate engagement on a regional, entity, and practice level the scores that are being assessed Results categorized by high, medium, low Monthly reports shared with Markets on all practices Quarterly results are presented on practices that are categorized as Red or Yellow from CMID Quarterly results determine the amount of involvement that will be recommended for the CTC to participate in with the practice Results support Consequence Management decisions Assessment Scale Touch point Engagement Transformation Performance Overall High Medium Low < 8 < 8 1 < Highmark s P4V programs are making an impact More than 69% of members in Western Pennsylvania now receive care within a Pay-for- Value program Western Pennsylvania Quality Blue ACA/PCMH 438 practices representing 68 PCMH and 77 ACA entities 1,538 practitioners 548,540 attributed members West Virginia Quality Blue PCMH 92 practices representing 30 PCMH entities 383 practitioners 36,437 attributed members More than 60% of members in Central Pennsylvania now receive care within a Pay-for- Value program Central Pennsylvania Quality Blue PCMH 334 practices representing 57 PCMH entities 2,002 practitioners 335,402 attributed members Delaware PCMH Pilot 38 practices 113 practitioners 35,320 attributed members More than 900 practices More than 4,000 practitioners More than 955,000 members Note: figures are current as of September 30, 2014, 32 16

17 Program Successes Most rapidly growing P4V program in region with focus on quality, cost trends and accountability Strong improvement and focus on Population Health Central PA: 335 practices; 2,002 practitioners > 335,402 attributed members More than 35% improvement in Quality metrics Significant improvements in admits, readmits, ER utilization Care cost trend 3% less than market resulting in $23,600,000 cost avoidance in first year!! 33 Quality Measure Improvements Commercial % Compliance March 14 July Adult BMI Assess Chol Mgmt LDL >100 % Compliance Diabetes - HbA1c <=9% 12 Diabetes - LDL -C < Approp Testing Peds Pharyngitis Urinary Incont Assess Falls Risk Assess Jun-13 Jul

18 Quality Measure Improvements Medicare Advantage % Compliance March 14 July Adult BMI Assess Chol Mgmt LDL <100 Annual Wellness Visit % Compliance June 13 July 14 0 Diabetes HbA1c </=9% Diabetes LDL C <100 Urinary Incont Assess Falls Risk Assess 35 P4V means a new level of access for patients Practices will be expected to: Provide SAME DAY appointments for routine care, preventive care, and chronic condition follow-up care, in addition to appointments for sick or urgent needs Return phone calls within the same day Provide clinical advice to patients when the office is not open Document all phone conversations Have appointments available after 5 pm on weekdays and/or weekend appointments Have the ability to access the patient clinical record when the office is closed Have written policies on phone calls, patient messaging, and off-hours access. Patients must be able to electronically: Receive an electronic copy of their health information Obtain a clinical visit summary Access their health information Request and schedule appointments View test results Ask clinical questions or request clinical advice 36 18

19 Transformation is not just trying harder It is not enough to do a good job at what you are already doing. You have to change what you are doing. Success in Pay-for-Value calls for unprecedented levels of care coordination and population management. Care coordination might entail: Creating lists of patients by diagnosis or chronic condition Listing patients by health risk (e.g. smokers) or other unhealthy behaviors and/or mental health issues to counsel and medicate Using lists of patients with chronic conditions to track gaps in recommended care Creating lists of patients who are due or overdue for tests or preventive care Following up with patients who are overdue for preventive care Creating lists of patients who are taking specific medications Identifying patients who are complex, high risk and/or vulnerable 37 Accountability and Transparency Revolution Old Charlie stole the handle and the train won't stop going, no way to slow down. Locomotive Breath from the album Aqualung, music and lyrics Ian Anderson 38 19

20 Pay for Value Programs: Levers of Opportunity Benefit Design Reference Pricing Profiling/Steering Tiered Networks Value Modifier/ Multiplier Procedural Bundles Prospective Retrospective Fee Schedule Modification/ Enhancements Prior Authorization Medical Management Gain Share/ Risk Share 39 Specialist Neighborhood won t be a silver bullet Bundles Population Targeted/ Strategic CPA Cardiology Specialty Specific Dialysis P4V CPA Onc High cost 40 20

21 Specialist Efficiency: Unit Cost and Utilization Drivers Orthopedic Surgeon Cost Efficiency Hospital System Preferred Non-Preferred Large Monopoly Allowed per Episode Actual $2,778 $3,137 $5,148 Expected $3,015 $2,934 $2,790 Dollars per RVU $33.66 $35.00 $72.95 Efficiency* Overall Unit Cost Utilization * An efficiency of 1.00 is average efficiency, which would equate to a PPA score of Continued Challenges & Continued Evolution Focused commitment to transformation EHR limitations Limited resources within practice to dedicate to transformation Limited resources to mine PI Tool Office turnover Working with Entity Administration vs. Practice Level Provider buy in of ability to make changes in PMPM costs Provider committee in CA patients want to go where they had others things done (i.e. knee replacement 42 21

22 Lessons Learned You must make it easy for the provider to see what is important Data must be actionable Reports must be structured in way that it beneficial to the provider Many providers struggle with data analysis; have support available Provide detailed roadmap for each metric in program; Ensure practice understands definitions Variability exists in provider readiness to engage in the new care models. thus impacting overall program performance Prepare cohort views of provider performance Expensive, resource intensive, long road. Do not underestimate resistance and learning curve. Stakeholder opposition is firm, well informed, well connected. 43 Lessons Learned External Provider Too many resources touching provider causes confusion Providers want a feedback loop Many providers need help navigating cost data Transformation is difficult; seeing more success in those practices having resources to dedicate Provide multiple modalities for practice education Internal Plan Thoughtful consideration to who is onboarded into ACA/PCMH programs Communication amongst internal teams is critical Strict quality controls necessary at each step of process Perform due diligence with vendor tools to ensure matching program definitions Create consistency in outbound materials wherever possible Clearly define roles of field teams Create consistent way to document & communicate touch points and engagement status across field teams 44 22

23 The future ain t what it used to be. Yogi 45 Questions 23