Presentation to Primary and Mental Health Reimbursement Task Force Robert Gluckman, MD, FACP Chief Medical Officer, Providence Health Plan May 16, 2014
PMPM PHP Commercial Per Member Per Month Expenses (Portland Service Area Only) 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 PCP Spec Facility Fee RX Admin
Payer Concerns on Cost Drivers for Commercially Insured Members Cost shift due to low public payer rates Provider Consolidation Rising Administrative Burden/Mandates Provider oversupply for some services Cost of New Treatments Hepatitis C, Chemotherapy, Marginally beneficial technology Variation in delivery of services
#5 PEBB Cardiac Procedure rates by Top 6 Regions (Jan 2010-Sep 2011) 4
CAD Presentation in Patients Receiving PCI 100% 90% 80% 70% 63.5% 48.6% 50.6% 50.6% 31.4% 27.4% 60% 50% 40% 30% 20% 10% 0% 34.3% 56.3% 36.8% 36.8% 44.1% 30.4% 21.6% 10.1% 1.6% 10.4% 3.1% 11.0% 2.4% 12.7% 3.1% 5.1% 2.9% 5.9% A B C D E F No Symptoms and Symptoms Unlikely to be Angina Stable Angina Unstable Angina Non-STEMI and STEMI
Large Statewide Employer Caths/1,000 in a High Use Community 9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0 Q1 2010 5.9 Q2 2010 6.9 Q3 2010 7.3 Q4 2010 6.5 Q1 2011 8.3 Q2 2011 Cath Rate/1,000 Cath Rate/1,000 5.3 Q3 2011 6.9 Q4 2011 3.8 Q1 2012 5.6 Q2 2012 5.3 Q3 2012 3.4 3.6 Q4 2012 Linear (Cath Rate/1,000) Q1 2013 4.3 Q2 2013 3.6 3.6 Q3 2013
Count of PCPs PCP Quality Profile Improvement Family Practice and Internal Medicine 250 What to look for... 200 13% increase in mean quality score: higher quality of care. 16% reduction in variation: more consistent quality of care. 150 2005 2010 100 2013 50 0 60% 62% 64% 66% 68% 70% 72% 74% 76% 78% 80% 82% 84% 86% 88% 90% 92% 94% 96% 98% Overall Quality Score Prepared by CPM/jrs
Patient Acuity Cared for by Different PCP Providers- Commercial Only 2.00 1.90 1.80 1.8 1.70 1.60 1.62 1.60 1.50 1.40 1.30 1.44 1.39 1.42 1.49 1.32 1.25 1.20 1.10 1.00 PCP Group Multi Group PMG Family Practice Internal Medicine Nurse Practitioner
Office Visit Billing Patterns 60.0% 51.5% 50.0% 41.5% 45.0% 40.0% 32.3% 30.0% 27.1% 26.1% 20.0% 10.0% 0.0% 3.0% 2.2% 3.1% Est Outpt L2 Prob Foc H&E Strtfwd Est Outpt L3 Exp Prob H&E Low Complx Med Est Outpt L4 Dtl H&E Mod Complx Dec 1.2% 2.5% 1.5% Est Outpt L5 Comphnsv H&E Hi Complx Family Medicine Internal Medicine Nurse Practitioner
Frequency of total office visits related to Diabetes Mellitus 3.00% 2.80% 2.50% 2.40% 2.10% 2.00% 1.50% 1.00% 0.50% 0.00% Diabetes Mellitus Family Practice Internal Medicine Nurse Practitioner
Frequency of Office Visits Related to URI 8.00% 7.50% 7.00% 6.00% 5.00% 4.00% 3.90% 3.00% 3.20% 2.00% 1.00% 0.00% URI/Sinisitis Family Practice Internal Medicine Nurse Practitioner
MD and Nurse Practitioner Comparative Analysis Purpose: Comparative analysis of utilization and prescribing patterns for MD and Nurse Practitioners with prescribing privileges within Oregon and nationally. Utilization Data 489,032 outpatient treatment episodes with episode start dates in 2012 and episode end dates up to 12/31/13. Episodes constructed from paid behavioral health claims Episodes begin with first outpatient date of service between member and provider after 120-day negative claims period Episodes end after 12-months or last outpatient date of service before a break of 120-days or more (within first 12-months) Member must be continuously eligible for measurement period 9,899 in-network providers with a minimum of 10 episodes. Pharmacy Data Psychotropic claims with fill date in 2013 for Optum-UHC shared business. Does not include Providence membership. 12
Patient Profiles Oregon MD Oregon RN National MD National RN Adults 83.2% 88.3% 84.6% 87.3% Males 58.1 64.5 57.6 63.8 Product Commercial 87.7% 83.2% 83.9% 79.8% Medicare/Medicaid 12.3 16.8 16.1 20.2 Use of BH Facility Based Care 6-mos prior to Episode 10.0% 6.7% 13.2% 10.5% 12-mos after Episode Start 7.6 2.4 6.0 4.0 Diagnosis Depression 37.1% 34.3% 40.9% 38.7% Bipolar 14.0 13.2 12.4 12.6 Anxiety 31.3 28.7 27.5 29.3 ADHD 18.0 16.8 15.6 13.9 Psychosis 4.0 5.0 4.6 4.2 Substance Abuse 3.7 1.4 5.6 3.7 Adjustment Disorder 4.1 6.1 3.9 5.9 Within Oregon, differences between MD and RN that were significant (p<.01) are highlighted in bold. Nationally, all differences between MD and RN were significant (p<.01) with exception of percent of episodes with Bipolar, Psychosis, and Eating Disorders 13
Average Number of Visits (ANOV) There were no statistical differences in ANOV between MD and RN s either within Oregon or Nationally. However, Oregon MD s and RN s had higher ANOV than their national peers (p<.0001). The case mix model suggests that the ANOV for both MD and RN s in Oregon are higher than the patient case mix would predict, with MD s showing a slightly larger residual than RN s Region Provider Type Providers Episodes ANOV ANOV Case Mixed ANOV Residual Oregon National MD 133 5,513 5.1 4.2 0.9 RN 82 3,073 4.6 4.3 0.3 MD 8,472 433,680 3.5 3.6-0.1 RN 1,212 46,010 3.6 3.8-0.2 14
Prescribing Patterns MD s had slightly higher rates of patients with non-adherence than RN s. There was no difference between MD and RN in the rate at which their patients triggered the fourth algorithm. Antidepressant Non Adherence* Antipsychotic Non Adherence* Mood Stabilizer Non Adherence* Supratherapeutic Dosing Sedatives and Hypnotics Prescriber Type Prescribers Patients Prescribed Medication % Patients Triggering Algorithm MD 9,774 109.982 51.7% RN 2,202 17,089 49.3% MD 7,725 44,814 56.2% RN 1,606 7,522 51.8% MD 7,268 37,783 54.6% RN 1,551 6,465 51.5% MD 5,205 20,166 18.9% RN 979 2,665 17.7% * Differences between MD and RN significant at p<.01. 15