ACC MDI 2006 BCBSM Value Partnership Strategy: Physician Group and Hospital Perspectives Ben D' McCa

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ACC MDI 2006BCBSM Value Partnership
StrategyPhysician Group and Hospital
PerspectivesBen D. McCallister, Jr,
MDPresident Michigan Heart, PCAnn Arbor, MI
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Threats to CV Quality Initiatives

• Decreasing Reimbursement Financial Uncertainty
• Practices are getting desperate to cover overhead
• Quality projects at risk due to budget cuts
• Pushing unqualified docs to do ancillaries
• Unreliable results leading to unneeded care
• More difficult to ask low volume docs to give up
  procedures credentials
• Practices increasingly selecting patients based
  on reimbursement type

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Pay for PerformanceMichigan Hearts Vision

• Maintain the physicians primary role as the
  patients advocate
• Provide high quality, timely, cost effective
  safe cardiovascular care.
• Raise quality and consistency of cardiovascular
  care in Michigan.
• Partner with payers willing to help make a
  quantum leap CV care quality

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PARTNERING WITH BCBSM

• Regional Collaborative Projects
• BMC2 PCI project
• Michigan Society of Thoracic and Cardiovascular
  Surgeons Cardiac Surgery Collaborative (MCSC)
• Cardiac CTA - Advanced Cardiac Imaging Consortium
  (ACIC)
• Physician Group Incentive Program (PGIP)
• Cardiovascular Centers of Excellence
• Outpatient EMR Disease Management Grant

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Blue Cross Blue Shield of Michigan Cardiovascular
ConsortiumCollaborative Quality Improvement
Initiative In Coronary Angioplasty
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BMC2 Hospitals
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PCI/BMC2

• Started in 1999
• 14 Michigan hospital comparison/benchmark -
  audited
• MACE (CVA, CABG, vascular complication,
  transfusion, acute closure, MI, mortality)
• Technical outcomes like side branch occlusion,
  complexity of lesion
• Contrast use, fluoro time, IIBIIIA use, IABP use,
  etc
• All operators (except one who no longer does PCI)
  have met ACC/AHA volume standards

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PCI BMC2

• Advantages
• Regional benchmarking
• Identified issues that were unrecognized
• Vascular complications, transfusion rates
• Follow up data to track improvement after
  intervention
• Motivator for quality
• Physician peer data report cards
• Reviewed blinded as a group
• Reviewed individually with cath lab medical
  director

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Michigan Cardiac Surgery Collaborative

• Share data
• Benchmarking
• Peer site visits

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Cardiovascular Centers of Excellence

• Bonus - of all BCBS reimbursement
• Put into SJMH general funds
• None to physicians so far

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Hospital Incentive Program Centers of Excellence

• Total estimated value of incentive
• 5.5 million per year
• - 1 million at SJMLH
• - 4.5 million at SJMH

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Cardiovascular Centers of Excellence

• Led to quality changes
• Doing much of this already, but took off some
  financial heat
• Explains to other specialties why we have extra
  support
• SJMH committed to obtaining COE designation
• Specialty projects
• Inpatient CHF care with transition to outpatient
  care
• Door to Balloon time refocused
• Validated need for Clinical Practice Teams
• Appropriateness tracking (cath)

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Physician Group Incentive Program

• Focused on PCPs so far - specialists next
• CAD CHF (also Asthma and Diabetes)
• Plan designed in coordination with cardiology
• Education of PCPs and patients
• Pharmacy use education for cardiologists
• Effective clinical improvement and pharmacy
  control required cooperation of BOTH cardiology
  and PCPs

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Outpatient EMR Disease Management Grant

• Generic Use rates - ACEI/ARB, statins
• Office visit templates with quality reminders
• Outpatient contracts
• Automatic patient education/reminder sheets
• Linked to web education
• Dynamic quality reminders
• Local EMR data consortium
• Coordinated care between PCPs and specialists

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Post-MI Office Visit Template
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Quality Reminders - Office Visit
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ANN ARBOR AREA INTEGRATED HEALTH EXCHANGE

• What is it?
• Common repository for EMR data - Nextgen
• Who is in it?
• Private practice groups
• Huron Gastroenterology
• Michigan Heart
• IHA primary care
• Michigan Multi-specialty Practice
• How it works?
• Currently privately owed with plans to go to
  nonprofit public utility model
• Future?
• Open to all community physicians and hospitals

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A3HIE

• Currently
• Shared demographics, meds, allergies
• Hospital lab test results
• Automated specialty referral process
• Near future
• All hospital dictated reports
• Unified past medical, family and social histortes
• Future
• Unified problem list

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Pay for PerformanceMichigan A Successful Model

• Maintain the physicians primary role as the
  patients advocate
• Incentives for high quality, timely, cost
  effective safe cardiovascular care.
• Raising quality and consistency of cardiovascular
  care in Michigan.
• Partnering with a payer willing to help make a
  quantum leap CV care quality

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Pay for PerformanceWhats Happening Elsewhere

• screening with Lipid Panels
• of CAD patients on statins
• Ace Inhibitors use in MI and CHF
• Beta-blocker use post-MI
• A-Fib with CHF on warfarin
• Radiology procedure use rates
• Length of stay
• prescriptions written per episode of care
• Generic use rates
• Rudimentary and primarily inpatient care
• We need to do much more.

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Pay for PerformanceRaising the Bar

• Lipid Panels/Statins gt at LDL goal
• Ace Inhibitors/ Beta-blocker gt adequate dose -
  BP, HR
• A-Fib with CHF on Warfarin gt at goal INR
• Radiology procedure use rates gt meet
  appropriateness criteria
• prescriptions written per episode of care
• Generic use rates gt Preventative monitoring
  for side effects gt Prevention of drug
  interactions gt Prescriptions coordinated
  between PCPs and specialists

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Hospital Incentive Program Centers of Excellence

• Total estimated value of incentive
• 5.5 million per year
• 1 million at SJMLH
• 4.5 million at SJMH
• 20 consortium participation
• BMC2, Mich.CT Surgeons Quality Improvement
  Initiative, Mich. Surgery Quality Consortium,
  Mich. Breast Oncology Initiative MHA Keystone
  Project
• 35 Core Measure of performance
• 35 Measure of efficiency
• 10 HCAHPS Patient Satisfaction score

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• New resources are needed to help physician
  groups to achieve optimal systems
• Private practices are scrambling to cut costs due
  to upcoming reimbursement cuts
• Physician time increasingly scarce
• Elective quality projects are at risk
• Investment in EMR less likely

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Hospital Incentive ProgramLessons Learned

• Physicians should be included in the
  incentive program

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Pay for PerformanceHow About the Outpatient
Arena?

• Diagnostic Testing
• Accreditation and Credentialing
• Compliance and Cost Issues
• Disease Management
• Facilitating Return to Work
• Specialty collaboration
• e.g.. Dyspnea Chest Pain clinics
• PCP - Specialty collaboration

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Pay for PerformanceDIAGNOSTIC TESTING

• More Effective Testing
• Appropriateness criteria ? too hard to monitor
• Benchmark use rates - Focus on overall average
  use, not defending the use for individual cases
• Develop standards for frequency of repeat testing
  and track repeat use rates
• Reduce duplicate testing
• Better access to previous test results
• EMR flags to prevent duplicate testing
• Higher quality test, avoid redo testing

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Pay for PerformanceDIAGNOSTIC TESTING

• ACCREDIDATION AND CREDENTIALLING
• Proliferation of diagnostic studies to the O/P
  setting
• Should lower the cost/test
• More convenient, improved access
• Poor quality tests or reports can cause
  unnecessary treatment and repeat of studies
• Is there an opportunity to set standards for the
  O/P setting? Improve quality while lowering
  costs.
• Credentialed physicians and technicians
• Accredited labs

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Pay for Performance

• COMPLIANCE AND COST ISSUES
• Better assurance for delivery of treatments
  demonstrated to lower the incidence of disease.
• ICD in low EF
• Aspirin in CAD
• Can we improve patient compliance in proven
  preventative medicine protocols?
• Can we lower costs by using generic drugs when
  suitable?
• E.g. Aldactone vs. eplerenone, Zocor vs.
  simvistatin
• Can we avoid polypharmacy?
• E.g. simvistatin vs. pravachol and zetia
• Coordinate PCP and specialists prescribing
• Compliance with cath/imaging appropriateness
  guidelines

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Pay for Performance

• DISEASE MANAGEMENT
• Using EMR to drive consistency quality of care
• Areas to consider might include
• post-MI care
• CHF
• Atrial fibrillation
• Coumadin management
• Lipid management in CAD and PVD
• Comprehensive management of cardiovascular
  disease in diabetics
• Decreasing Admissions and Use of Emergency Room
• Post-PCI, MI, CHF, syncope, Afib

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Pay for Performance

• RETURN TO WORK ISSUE
• Return to work is a major concern for employers
• Opportunities to fast track the employee
  out-of-work for cardiac reasons
• Guaranteed rapid evaluation
• More rapid testing

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Quality Tenets

• Commitment to excellent care
• Consistency
• Using ACC/AHA guidelines
• Outcomes only way to assess care
• effectiveness or complications
• External assessment/report carding
• Physician/Hospital collaboration
• Pay for performance programs
• Internal harmony
• Good care is good business

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MHVI Quality Report

• Patient Satisfaction
• Referring Physician Satisfaction
• Staff Satisfaction
• Non-invasive Cardiac Testing
• Percutaneous Coronary Intervention
• Door to Balloon Time Project (Primary PCI for
  acute MI - onsite and transfers)
• Cardiothoracic Surgery Reports

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Individual Providers Michigan Heart
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15 other Cardiology groups
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Threats to CV Quality Initiatives

• Decreasing Reimbursement Financial Uncertainty
• Practices increasingly selecting patients based
  on reimbursement type
• More de-participating
• Fill schedules with better paying patients, use
  unfilled schedule for poorer paying patients
• Higher risk patients (eg. MC, MD, HMOs) may not
  have access for frequency of care needed for
  quality care

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Threats to CV Quality Initiatives

• Rapid growth of substandard testing and
  procedures
• If I can bill it, I can do it.
• Need for for quality standards linked to
  reimbursement
• Credentialing and accreditation

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PARTNERING WITH BCBSM

• Physician Group Incentive Program (PGIP)
• Focused on PCPs so far
• CAD CHF
• Regional Collaborative Projects
• BMC2 PCI
• Michigan Society of Thoracic and Cardiovascular
  Surgeons Cardiac Surgery Collaborative (MCSC)
• Cardiac CTA - Advanced Cardiac Imaging Consortium
  (ACIC)
• Cardiovascular Centers of Excellence
• Outpatient EMR Disease Management Grant
• Generic Use rates - ACEI/ARB, statins
• Office visit templates with quality reminders
• Outpatient contracts/reminder sheets web
  education
• Dynamic quality reminders
• Local EMR data consortium - coordinated care

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Accomplishments to Date

• Trusting relationships
• Database implementation over 100,000 consecutive
  cases
• Quarterly comparative reports across
  hospitals/operators

AGREE
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Accomplishments to Date

• Evidence based learning linking processes and
  outcomes of care
• Disseminated in peer-reviewed literature
• Development of care management algorithms
• CQI interventions demonstrable improvement in
  selected processes and outcomes of care
• Using RCTs across hospitals to learn what works

AGREE
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Accomplishments to Date

• Dramatic decreases in mortality rate (-27), and
  in rates of complications, including AMI
  (-19), CABG (-22), renal failure (-57)
• Cost savings of approximately 8,000,000 annually
  due to prevention of AMI, CABG and renal failure
  requiring dialysis
• over 8,000,000 annually statewide for
  participating hospitals 2,400,000 attributable
  to care of BCBSM members

AGREE
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BMC2 Lessons Learned

• Blue leverage was key to convening competing
  providers and catalyzing effective, collaborative
  CQI
• Given procedure-specific information, and
  incentives, competing providers can collaborate
  and rapidly improve the quality of care
• Incentives to rigorously evaluate and re-engineer
  care accomplish more than focusing on selected
  performance metrics

AGREE
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Hospital Incentive Program

• Pre-qualifying conditions focus on culture of
  safety and patient safety practices (ISMP NQF)
• 45 - 55 Quality and Patient Satisfaction
• 35 Efficiency (e.g., cost per case regional
  comparison generic drug use)
• 10 - 20 Collaborative Quality Initiatives