National ACO Summit. Third Annual. June 6 8, Follow us on Twitter and use #ACOsummit.

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1 Third Annual National ACO Summit June 6 8, 2012 Follow us on Twitter and use #ACOsummit. The Engelberg Center for Health Care Reform at Brookings The Dartmouth Institute

2 Infrastructure for Quality Improvement Gene Lindsey, MD President and CEO Atrius Health and Harvard Vanguard Medical Associates ACO Summit

3 Atrius Health Non-profit alliance of six leading independent medical groups Granite Medical Dedham Medical Associates Harvard Vanguard Medical Associates Reliant Medical Group Southboro Medical Group South Shore Medical Center Provide care for ~ 1,000,000 adult and pediatric patients in almost 50 ambulatory sites 1000 physicians, 1450 other healthcare professionals across 35 specialties Largest physician-based Accountable Care Organization

4 Atrius Health 100% on EMR combined with corporate data warehouse, used for managing quality and cost. Patient portal. Long history with global payments, currently managing 50% of our patients with global payments across commercial, Medicare and Medicaid populations. Strong infrastructure to manage risk One of first to sign BCBSMA Alternative Quality Contract (AQC) One of 32 Medicare Pioneer ACOs nationally

5 The concept of an Accountable Care Organization is not new The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money. These problems can only be solved by organizing the personnel, facilities and financing into a conceptual framework and operating system that will provide optimally for the health needs of the population. Dr. Robert Ebert, Founder, Harvard Community Health Plan,

6 Our Focus is on Achieving Quality The Triple Aim IOM Definition Reduce Per Capita Cost Improve Population Health Improve Experience Of Care Patient-centered Safe Effective Efficient Equitable Timely And sustainable Source: IHI.org

7 Our Challenge is to Move From Physiciancentered system To Patient Centered system Volume-based reimbursement Value-based reimbursement Price focus Total Medical Expense

8 Atrius Health ACO Strategies Foster culture of quality and service to patient Strengthen our distributed physician leadership at all levels in the organization Continue our LEAN journey to improve quality, patient safety, patient experience, and reduce costs Implement & spread Patient Centered Medical Home, including management of high risk populations Create compact with staff at every level to clarify roles at top of license Strengthen collaboration across specialists, hospitals, and post-acute care to be successful Accountable Care Organization without hospital ownership

9 Two Kinds of Change: Technical Problem is well-defined Solution is known, can be found Implementation is clear Adaptive Challenge is complex To solve requires transforming long-standing habits and deeply held assumptions and values Involves feelings of loss, sacrifice (sometimes betrayal to values) Solutions requires learning and a new way of thinking, new relationships From Jack Silversin, Amicus

10 Atrius Health: Challenge of Hospital and ED Information All Hospitals Hospital Partners Most Hospitals In 2011, Atrius Health patients visited: 25 different hospitals with 100+ admissions 39 different hospitals with 100+ ED visits Monthly Claim Feed 10

11 Robust Data Management Infrastructure is critical Browser Smart Client Epic RWB / RADAR Crystal / WebI / Xcelsius MS Excel/Access DxCG/ 3M APR DRG SPSS Verisk SMI Quality Management Practice Management Encounters / RVU Medical Expense Management Patient Experience Management CLARITY All PAYER CLAIMS PATIENT EXPERIENCE Clarity Console(ETL) Oracle Warehouse Builder (ETL) EPIC Suite Payer Data (Medical Claims,Pharmacy,Member Eligibility) Tufts Health Plan Tufts Medicare Neighborhood Health Plan HPHC 11 BCBSMA CMS Pioneer Press Ganey

12 Tactics to Achieve Quality Measures require clinical interventions across populations

13 Lean Methodology provides Focus on Adding Value and Use of Common Approach From Simpler Consulting

14 Sustainable Primary Care Practice: The Patient-Centered Medical Home The Medical Home is not a place, but rather an approach to providing comprehensive, patient-centered primary health care. The Primary Care Physician (PCP) works in partnership with the patient and family to assure that his/her medical and health-related needs are met through accessible, coordinated, culturally-sensitive care delivered on a continuous basis and across all disciplines, settings and services in order to achieve optimum health outcomes and quality of life. The Medical Home. Pediatrics. 2002; 110;

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16 Adaptive Change: We will challenge Simple rules I am accountable We are accountable From Accountable Care Organizations, Marc Bard and Mike Nugent, 2011

17 Problems must be solved by those who do the work

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19 Outstanding Clinician and Staff Experience Respect as a basic principle Communication weekly from CEO Involve the front line in Lean Site Councils Leadership Academy Chief development Atrius Standard Model for Epic Governance structure Go to the Gemba

20 Federalist Model In democratic countries, knowledge of how to combine is the mother of all other forms of knowledge; on its progress depends that of all the others. Alexis de Tocqueville Democracy in America Out of Many, One

21 L E A D E R S H I P Leadership Academy January 2008 (19 participants) Leadership Academy September 2008 (33 participants) Leadership Academy II January 2009 (37 participants) Leadership Academy III October 2009 (35 participants) Leadership Academy IV January 2010 (45 participants) Leadership Academy V September 2010 (37 participants) Leadership Academy VI January 2011 (38 participants) D E V E L O P M E N T

22 Evolution of Physician Compensation The Value Model: Group paid mostly for Value, Physicians paid mostly for Value (or salaried) The Funky Model: Group paid mostly for Value, Physicians paid mostly for Volume The Charitable Model: Group paid mostly for Volume, Physicians paid mostly for Value (or salaried) The Volume Model: Group paid mostly for Volume, Physicians paid mostly for Volume From Craig Samitt, Dean Clinic 22

23 Outstanding Quality Measurement DM Composite Outcomes: LDL control, HbA1c Control, BP control

24 We have flattened the cost curve for commercial risk patients

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26 Reflections The future we predict today is not inevitable. We can influence it, if we know what we want it to be We can and should be in charge of our own destinies in a time of change. Charles Handy The Age of Unreason

27 Track 2: Implementing Performance Measures Panel 1: Infrastructure for Quality Improvement Gene Lindsey, MD President and Chief Executive Officer, Atrius Health James Fanale, MD Senior Vice President of System Development, Jordan Hospital Marcia Guida James, MS, MBA CPC Director, Provider Engagement, Humana Penny Wheeler, MD Chief Clinical Officer, Allina Hospitals & Clinics Chris Queram, MA President and Chief Executive Officer, Wisconsin Collaborative for Healthcare Quality (Moderator)

28 Patient Reported Outcome Measurement: Progress and Promise Dana Gelb Safran, Sc.D. Senior Vice President Performance Measurement and Improvement Blue Cross Blue Shield of Massachusetts Presented at: ACO Summit 7 June 2012

29 Advancing Quality, Outcomes and Affordability: Aligning Member and Provider Engagement Strategies Reporting to Providers Member Incentives & Benefits Provider Incentives Reporting to Public Blue Cross Blue Shield of Massachusetts 29

30 What are PROMs? Measures of a patient's health status or health-related quality of life Standardized patient reported data, collected over time in a consistent manner so results can be measured, analyzed, and used in research and care delivery. Provides information on key dimensions of patient functional status and well-being; inform diagnosis and treatment decisions. Quantifies the impact of treatments in ways that can inform clinical practice and quality measurement. Blue Cross Blue Shield of Massachusetts 30

31 What are PROMs? The data collected through PROMs provides clinicians and researchers with information that cannot be identified through a typical clinical indicator or process measure. 11. The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? Yes, Yes, No, limited a lot limited a little not limited at all a. Climbing several flights of stairs b. Climbing one flight of stairs Blue Cross Blue Shield of Massachusetts 31

32 Collecting and Using PROMs Paper Phone/IVR In-office tablet Patient Portal Blue Cross Blue Shield of Massachusetts 32

33 PROMs in Practice PROMIS (Patient Reported Outcomes Measurement Information System) Funded by NIH grant in 2004, PROMIS is a survey item bank of rigorously reviewed measures of patient reported health status for physical, mental, and social well being Standardized domains and metrics exist across conditions The PROMIS initiative is carried out by a network of 12 NIH funded primary research sites each with an active study utilizing PROMIS tools PCORI (Patient-Centered Outcomes Research Institute) PCORI was established under the Patient Protection and Affordable Care Act of 2010 (PPACA) Mission: to fund research that offers patients and caregivers the info they need to make informed healthcare decisions Accelerating patient-centered research is one of five PCORI research priorities PROMS in the U.K. Starting on April 1, 2009 all providers of NHS-funded care have been required to collect PROMs for these four clinical areas: hip replacement, hernia surgery, knee replacements, varicose vein surgery From 4/11 to 12/11, 131,000 pre-op and 50,000 post-op PROMS surveys completed 87.7% of hip replacement respondents and 79.4% of knee replacement respondents recorded an increase in their general health following their operation (EQ-5D index) Blue Cross Blue Shield of Massachusetts 33

34 PROMIS Domains Blue Cross Blue Shield of Massachusetts 34

35 Meaningful Use Phase 2 (Final Rule Pending) CLINICAL QUALITY MEASURES PROPOSED FOR MEDICARE AND MEDICAID ELIGIBLE PROFESSIONALS INCLUDES PROMS BEGINNING CY 2014 Functional status assessment for: Knee replacement Hip replacement Complex chronic conditions Blue Cross Blue Shield of Massachusetts 35

36 Pathway to Accountability for PROMs Phase I Initial integration into practice workflow and culture Phase II Population level uses such as shared decision making Phase III Accountability for outcomes PROM Development: Continued extensive psychometric and evaluative science needed to understand how and when PROMs can be used for accountability. Blue Cross Blue Shield of Massachusetts 36

37 Near- and Longer-Term Promise of PROMs Patients and Families Improved clinical interactions Empirical basis for treatment decisions Meaningful data on quality to inform choice Payers/Purchasers Tools to promote focus on health and health outcomes Improved evidence base on efficacy and basis for informed decision making Ability to measure and improve outcomes PROMs Clinicians/Systems Monitor patient progress Data to guide treatment decisions Improved evidence-base for care Compete on evidence of better results Blue Cross Blue Shield of Massachusetts 37

38 For More Information Blue Cross Blue Shield of Massachusetts 38

39 Track 2: Implementing Performance Measures Panel 2: Implementation Path to Patient Reported and Outcomes Measures Dana Safran, ScD Senior VP for Performance Measurement and Improvement, Health Care Services Division, Blue Cross Blue Shield of Massachusetts, Associate Professor of Medicine, Tufts University School of Medicine Phil Polakoff, MD, MPH, MEnvSc Managing Partner, Polakoff/Boland Franklin E. Bragg, MD, FACP Primary Care Quality Assessment and Performance Improvement Activities Coordinator, Eastern Maine Medical Center Jennifer L. Jackman Senior Vice President, Accountable Care, Monarch HealthCare Mark McClellan, MD, PhD Director, Engelberg Center for Health Care Reform, Brookings Institution (Moderator)

40 Third Annual National ACO Summit June 6 8, 2012 Follow us on Twitter and use #ACOsummit. The Engelberg Center for Health Care Reform at Brookings The Dartmouth Institute