MICAH Quality Network Population Insights Reporting and 2017 2018 PG5 P4P Program Year Updates Blue Cross Blue Shield of Michigan Hospital Incentive Programs August 18 th, 2017 Topics for Today s Discussion 1 Review Population Health Insights Report 2 Wexford/Crawford PHO Presentation 3 Review 2017 2018 Scoring Thresholds 4 Financial Impact of P4P Program 1
BCBSM Peer Group 5 P4P Program REVIEW: Population Insights Reporting Blue Cross Blue Shield of Michigan Hospital Incentive Programs August 18 th, 2017 2 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 PGIP participating Primary Care Physicians SubPO A Michigan Acute Care Hospitals SubPO C SubPO X BCBSM Members 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 3
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 PGIP participating Primary Care Physicians SubPO A SubPO C 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 75% of Hospital Business 15% of Hospital Business SubPO X SubPO X cost and use metrics: $225 PMPM 150 ED visits/1,000 50 IP admissions/1,000 10% of Hospital Business Hospital ABC population based cost and use metrics: $285 PMPM 202.5 ED visits/1,000 91.25 IP admissions/1,000 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 4 5
1) Understanding who your Physician Organization partners are: Drop down menu to select hospital of choice PGIP participating PO and SubPO groups with a shared patient population with the hospital Average # of BCBSM members per PCP in this group Total count of BCBSM members attributed to PCPs in this group Number of PCPs participating in PGIP with these PO/SubPO groups 6 2) Strength of volume driven relationships with physician partners: Proportion of hospital utilizing members who chose to seek care at YOUR hospital (n, %) PGIP participating PO and SubPO groups with a shared patient population with 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 7
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 doors 2) have a care relationship with a PGIP PCP 8 4) Reviewing your hospital s population based cost metrics: 9
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 (%) 10 Community Based Population Health Jacque Runyon RN, BSN, MSA Transitions of Care Project Lead & Beth Oberhaus RN, BSN, MBA, PMP Clinical Operations Director
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 12 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 13
What is a PCMH? 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 14 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 15
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 16 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) 17
How are we measured HEDIS The 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 18 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. 19
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? 20 Score card 21
Score Card Continued 22 How do we determine success 23
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. 24 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. 25
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 26 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 27
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 28 Wrap up 29
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. 30 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 31
The good the bad and the ugly Congestive Heart Failure Enhanced Recovery COPD Diabetes Behavioral Health Pharmacy 32 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 33
Process Success Physician Leadership Senior Leadership Commitment (PHO and Hospital) Community engagement Payer Funding Role acceptance (PHO, Hospital and Community) Appetite for change 34 Time to think outside the Box 35 35
Future Payment reform is Purposely Disruptive Advanced Payment Models (Risk based payment) CPC+ Bundled Payments MACRA/MIPS Risk based contracts SIM-Community Health Workers 36 Need to Excel at FFS While Building for Value Based Payment 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 Crossing the Crevasse Clinical Integration is a way for physicians and health systems to bridge the gap between FFS reimbursement world and tomorrow s (today s) value based payment world VALUE BASED PAYMENT Brave new world New business model Focus on populations and episodes of care Primary care becomes key Profits from higher quality care in home setting Longitudinal payments for chronic care Bundled payment Joint contracts with payers Focus on data 37
38 Thank you for improving health care for the people of Michigan 39