Special Legislative Council on Performance-Based Disease Management Programs Chronic Care Management

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Special Legislative Council on Performance-Based
Disease Management Programs Chronic Care
Management

• Marilyn A. Follen, RN, MSN
• Administrator Quality Improvement and Care
  Management
• Marshfield Clinic
• July 24, 2008

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Objectives

• Review the current realities.
• Definitions
• Review the CMS Physician Group Practice (PGP)
  Demonstration Project
• Value driven interventions
• Care management initiatives

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Marshfield Clinic

• Over 40 centers throughout northern, central and
  western Wisconsin
• 750 physicians in 80 medical specialties and
  subspecialties
• 361,436 patients served
• Patients seen from every county in WI, every
  state in the nation, as well as 25 foreign
  countries

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Marshfield Clinic

• Mission to serve patients through accessible
  high quality health care, research, and
  education.
• Long term strategy built around the six aims of
  the Institute of Medicine that care should be
• Safe
• Effective
• Patient centered
• Timely
• Efficient
• Equitable

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Institute of Medicine Crossing the Quality
Chasm

• Current care systems cannot do the job.
• Trying harder will not work.
• Changing care systems is the answer.

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Current Situation

• gt 100 million Americans have more than one
  chronic illness.
• gt 50 of patients dont get appropriate evidence
  based care Rand Corporation.
• Best practices could avoid 41million sick days
  and gt11 billion in lost productivity.
• Patients and family are increasingly recognizing
  defects in their care.

2004 Wagner
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Medicare Beneficiaries

• Chronically ill consume gt 95 of Medicare
  dollars.
• gt 75 have 4 chronic illnesses.
• The group with 4 chronic illnesses consumes
  2/3rds of Medicare dollars.
• Can no longer think in individual disease state
  management strategies given increasing numbers of
  patients with multiple chronic illnesses.
• Congressional Budget Office Study

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Current System Characteristics

• Fee-for-service
• Regardless of service value
• Disproportionately pays for the wrong things.
• Geographically adjusted

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Centers for Medicare Medicaid Services
(CMS)Physician Group Practice (PGP) Demonstration

• The first value-based purchasing demonstration
  applied to providers.

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CMS Physician Group Practice Demonstration

• Medicares first pay-for-performance
  demonstration for physicians
• Tests physician groups ability to lower costs
  and improve quality in traditional Medicare
  program
• 10 multispecialty physician groups with 215,000
  Medicare beneficiaries selected competitively
• Provides financial and quality-based payment
  incentives
• 4-year period beginning April 1, 2005

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Why enter the CMS PGP Project?

• Consistent with the Clinics mission
• Marshfield Clinics long term strategy built
  around the six aims of the Institute of Medicine.
• Marshfield Clinic was headed in the direction of
  value based health care which is consistent with
  the CMS PGP demonstration project.
• ALL interventions for the CMS PGP demo are
  applied to ALL Marshfield Clinic patients.

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One of Ten in the Nation

• Dartmouth-Hitchcock Clinic Hanover, NH
• Deaconess Billings Clinic- Billings, MT
• Forsyth Medical Group Winston-Salem, NC
• Geisinger Clinic Danville, PA
• Integrated Resources for Middlesex Area
  Middletown, CT
• Marshfield Clinic Marshfield, WI
• Park Nicollet Health Services St. Louis, MN
• St. Johns Health System Springfield, MO
• The Everett Clinic Everett, WA
• University of Michigan Faculty Group Practice
  Ann Arbor, MI

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PGP Objectives

• Align reimbursement with quality.
• Promotes using utilization and clinical data for
  improving quality.
• Encourage coordination of Part A (hospital) and B
  (outpatient) services.
• Promote efficiency in administrative structures
  and care processes.
• Reward for improving health outcomes.

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Process Outcome Measures
Blue process measures
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Medicare Physician Group Practice Demonstration
Project
CMS wants to avoid this!
We nt to avoid this situation
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Bottom Lines.

• Improving quality without improving efficiency
  results in ()
• Improving efficiency without improving quality
  results in
• Our challenge is to improve quality and
  efficiency, simultaneously

and fast.
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Marshfield Clinic Strategies

• Leverage Informatics
• Process Improvement Re-design
• Care Management
• Provider feedback
• Focus on Value

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Chartless Environment completed in 2007
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Marshfield Clinic Patient Informatics

• Electronic medical record (chartless in 2007)
• i (intervention) List Planned chronic illness
  care
• Dashboard diagnoses, medications, appointments,
  PreServ at a glance
• PreServ - preventive services needed by an
  individual

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Example of Chart Note for comprehensive DFE

• EXTREMITIES Without cyanosis, clubbing or edema.
  Pedal pulses present. Complete diabetic foot exam
  is performed. Dorsalis pedis and posterior tibial
  pulses are palpable. Skin and hair distribution
  are normal. Sensation is present at all 10 points
  on both feet.

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Work Directly With Each Department to

• Standardize care to best practice.

• Best Practice
• Safe
• Effective
• Patient-centered
• Timely
• Efficient
• Equitable

• Quality Improvement Care Management
• Systems Processes
• Clinic Operations

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How did we intervene for the PGP project?

• Multiple simultaneous interventions
• Best practice models developed for core
  conditions
• Computer based CME opportunities
• Care management programs
• Population based feedback to providers
• Physician/Clinical Nurse Specialist regional
  teams

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HTN Best Practice Model (BPM)

• Even the clinical practice playing field.
• Test a reasonable practice model that fills in
  where evidence gaps exist.
• Provide specifications toward which Departments
  manage clinical practice.

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Care Management

• Case management individual patients
• Care management populations of patients
• Blended Specific guideline driven protocols
  individualized for a patient
• Nurse Line (Triage)
• Anticoagulation Services
• Dyslipidemia Services

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Care Management Initiatives

• Nurse Line (Triage)
• Extension of providers practice
• Seamless access to care 24/7/365
• Guideline driven
• Standing orders
• Adult and pediatric triage guidelines are
  developed and reviewed by content experts with
  system-wide input from providers and nurses
• Support 335 primary care physicians system-wide
• Competency based staff training
• 6 week orientation program
• Test competence
• Extensive QI
• On-going feedback and education

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Care Management Initiatives

• Anticoagulation Care Management
• System-wide program
• 6,500 patients
• Staffed by RNs - work under common set of
  physician approved protocols
• 8 week orientation program
• Test for competence
• On-going feedback and education
• 6 week on-line certification course through
  Southern Indiana University

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Care Management Initiatives

• Anticoagulation Care Management
• Evidenced-based protocols
• Protocols are reviewed at minimum on an annual
  basis
• Care coordination
• Database
• Data housed in Data Warehouse
• Formal monitoring of metrics and outcomes
• AHRQ study revealed higher levels of
  anticoagulant control and fewer hospitalizations
  than the control group

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Anticoagulation An Example of Better, Less
Expensive Care Made Cost-Prohibitive by Current
Reimbursement Policy
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Anticoagulation An Example of Better, Less
Expensive Care Made Cost-Prohibitive by Current
Reimbursement Policy

• 5,000 patients/year on warfarin
• Medicare Savings 11.67 million
• Patient Savings 2.5 million
• Marshfield Clinic Costs (1.4 million)
• Reimbursement 0.00

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Care Management Initiatives

• Dyslipidemia
• Telephonic
• Medication management
• Educational focus
• Care coordination

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Lessons

• Adaptive change is challenging
• Cannot be mandated
• Occurs when care is delivered in a
  patient-centric manner with sound clinical
  underpinnings
• Provider trust and confidence builds with each
  new care management program
• Outcome data is essential
• Clinical outcome data
• Patient satisfaction data
• Provider satisfaction data

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Results
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Marshfield Clinic PY1 Results

• Marshfield Clinic
• Saved the CMS trust fund 6.02 million net of
  the 2 corridor (12 million if 2 corridor
  included).
• Improved quality measures from baseline
  measurement year.
• Met 9 of 10 quality measures.
• Earned a performance bonus of 4.5 million dollars

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Challenges

• For patients, purchasers, and providers in the
  future -

There will be a need to measure quality to prove
it is high while working to continually improve
quality and work to control costs to maximize
value in the marketplace.
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Challenges

• Competing definitions of quality from multiple
  payors
• Current reimbursement models do not support
• Practice redesign
• Care management efforts individual or
  population based
• Convincing payors to engage in sharing of cost
  savings for currently non-reimbursed services
  (nurse line, anticoagulation, etc).