Tim Ferris Presentation - Alliance for Health Reform

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Nov 25, 2013 (3 years and 8 months ago)

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The Engaged Provider Response to
the Current Health Care Policy
Environment


July 18, 2011


Timothy G Ferris, MD, MPH

Mass General Physicians Organization, Medical Director

Associate Professor, Harvard Medical School

2

The Engaged Doctor’s Dilemma


Uncertainty in payment reforms leaves the

engaged provider with little direction regarding

how to get started



So what is the engaged provider to do?


Whatever the new payment system, there are some clear directional indicators:


Change focus

-

from units to episode and populations


Move forward

-

move forward with the things that I know have been shown to improve
outcomes and/or reduce costs.


Always improve

-

create incentive structure that rewards continuous innovation

Inpatient and


Outpatient

Encounters

Episodes of Illness

Population
Management


Health care costs are rising too rapidly



We have been through this before


Healthy skepticism that the next big idea
from an insurance company is actually
going to solve this problem.



Physicians remain unsure of what
reform will bring


Multiple approaches in commercial, state,
and federal payers

3

Engaged Provider Tactics

Longitudinal Care

Episodic Care

Primary Care

Specialty Care

Hospital Care

Access to
care

Patient portal / physician portal

Optimize site of care

Extended hours / same day appointments

Reduced low acuity
admissions

Expanded virtual visit options

Design of
care

Defined process standards in priority conditions

(multidisciplinary teams, registries)

High risk care
management

Required patient decision
aids

Re
-
admissions

Hospital Acquired
Conditions

Provide 100% preventive
services

Appropriateness

Hand
-
off standards

Continuity Improvements

EHR with decision support and order entry

Incentive programs (recognition, financial)

Measurement

Internal variance reporting / performance dashboards

Publicly reporting of quality metrics: clinical outcomes, satisfaction

Costs / population

Costs / episode

4

Chronic Conditions


MGH Medicare Demo

Opportunity


10% of Medicare patients account for
nearly 70% of spending


MGH Demo



Medicare selected MGH to participate in a 3
-
year
demonstration project focusing on high
-
cost
beneficiaries in 2006



Success validated in 2010 (RTI evaluation)



Contract renewed through 2012



Expanded to Brigham and Women’s and North
Shore Medical Center

http://www.massgeneral.org/about/newsarticle.aspx?id=2531



Enrolled 2,500 highest cost Medicare patients with total
annual costs of $68 M


Average number of medications = 12.6


Average annual hospitalizations = 3.4


Average annual costs = $24,000



Payment model similar to proposed shared savings for ACOs


Paid monthly fee based on number of enrolled patients


Required to cover costs of program +5%


Gainsharing if savings greater than cost +5%


Success determined using prospective matched comparison
group





5

Chronic Conditions


MGH Medicare Demo

Results from Independent Evaluator (RTI)



12 care managers embedded in primary care practices


Coordinate care; point person for acute issues


Identify patients at risk for poor outcomes


Facilitate communication when many caregivers involved



Key characteristics


Care managers have personal relationships with patients


Care managers work closely with physicians


All activities supported by health IT (universal EHR, patient tracking, home
monitoring)



Successful Outcomes


Hospitalization rate among enrolled patients was 20% lower than comparison*


ED visit rates were 25% lower for enrolled patients*


Annual mortality 16% among enrolled and 20% among comparison



Successful Savings


7.1% annual net savings (12.1% gross) for enrolled patients


For every $1 spent, the program saved at least $2.65

*Based on difference in differences analysis

Scatterplot of outpatient CT examination volumes (y
-
axis) per calendar quarter
(x
-
axis) represented by red diamonds.

Sistrom C L et al. Radiology 2009;251:147
-
155

©2009 by Radiological Society of North America

Health IT


Integrated Decision Support for Imaging



Radiology utilization management systems

7

MGH Internal Physician Quality Measures

http://www
-
958.ibm.com/software/data/cognos/manyeyes/visualizations/mgh
-
quality
-
meas
-
overview
-
1209

8

MGH Internal QI Program Measures

HH and MRSA Rates
1.95
1.79
1.33
1.25
1.09
0.99
0.88
1.03
1.08
0.82
0.66
0.96
0.61
1.52
1.00
1.33
0.81
1.12
1.08
1.21
1.18
1.22
1.51
1.33
0.60
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Quarter 3
Quarter 4
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Quarter 1
Quarter 2
Quarter 3
2002
2003
2004
2005
2006
2007
2008
0.00
0.50
1.00
1.50
2.00
2.50
Before contact rates
After contact rates
MRSA Rate
Hand Hygiene / MSRA

EMR Use (for Notes)

78.5%
79.0%
79.5%
80.0%
80.5%
81.0%
81.5%
82.0%
82.5%
83.0%
Q1 09
Q2 09
Q3 09
Q4 09
Q1 10
Q2 10
Q3 10
Q4 10
Q1 11
Q2 11
Top Box %
Results
2010 Avg.
2011 YTD (prelim)
QI Target
2011 P4P Target
H
-
CAHPS

Performance

Radiology Turn Around Times

9

Engaged Provider Tactics: Meaningful Use

Engaged Provider Tactics: Partnership for Patients

Engaged Provider Tactics: Bundled Payment

Engaged Provider Tactics: Medical Home

Engaged Provider Tactics: HITECH

Longitudinal Care

Episodic Care

Primary Care

Specialty Care

Hospital Care

Access to
care

Patient portal / physician
portal

Patient portal / physician
portal

Optimize site of care

Extended hours / same day
appointments

Extended hours / same day
appointments

Reduced low acuity
admissions

Expanded virtual visit options

Expanded virtual visit options

Design of
care

Defined process standards in priority conditions

(multidisciplinary teams, registries)

High risk care management

Required patient decision aids

Re
-
admissions

Hospital Acquired Conditions

Provide 100% preventive
services

Appropriateness

Hand
-
off standards

Continuity Improvements

EHR with decision support
and order entry

EHR with decision support and order entry

Incentive programs (recognition, financial)

Measurement

Internal variance reporting /
performance dashboards

Internal variance reporting / performance dashboards

Publicly reporting of quality metrics: clinical outcomes, satisfaction

Costs / population

Costs / episode

Longitudinal Care

Episodic Care

Primary Care

Specialty Care

Hospital Care

Access to
care

Patient portal / physician portal

Optimize site of care

Extended hours / same day appointments

Reduced low acuity
admissions

Expanded virtual visit options

Design of
care

Defined process standards in priority conditions

(multidisciplinary teams, registries)

High risk care management

Required patient decision aids

Re
-
admissions

Hospital Acquired Conditions

Provide 100% preventive
services

Appropriateness

Hand
-
off standards

Continuity Improvements

EHR with decision support and order entry

Incentive programs (recognition, financial)

Measurement

Internal variance reporting / performance dashboards

Publicly reporting of quality metrics: clinical outcomes, satisfaction

Costs / population

Costs / episode

10

Closing Thoughts


Doing all this will take quite a while


the stakeholders will need to
be a little patient



How do we incent providers to do these other things?


Gold card status for engaged providers resulting in lower administrative
costs for payers and providers



This presentation addressed only the engaged provider side of a two
party relationship:


Incentives for patients to be judicious consumers of health care would
be a powerful complementary set of policies



Type types of innovation


Adopting and implementation of ideas known to be effective (i.e. “new”
processes)


Development and testing of new technology and processes not yet
known to be effective