Dealing With Payers With Physician Driven Cost And
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Transcript of Dealing With Payers With Physician Driven Cost And
Dealing with Payers with Physician Driven Cost and Quality Data
Hilton Sandestin Beach & Golf Resort, Destin
August 2, 2011William F. (Bill) Cockrell, FACMPE
What’s the Next “Big” Option“Accountable Care Organizations (ACOs),
Why They Will Fail and What We Will Need to Learn From the Experience”The main ingredients (who can argue with
these?)Cost Effective Quality
Because
In 2014 we have Healthcare Exchanges
Healthcare ExchangesThe Affordable Care Act requires each state to
establish by 2014 a health insurance exchange where individuals and small businesses can purchase affordable health insurance plans. The exchanges are the centerpiece of the reform law: they will be the main portals for people without employer-sponsored or public insurance to both find a health plan and learn about and apply for any federal subsidies for which they are eligible.
Essential Elements of a Healthcare Exchange *
offering the essential benefit package (to be determined in regulations later this year);
adhering to cost-sharing limits; being licensed and in good standing to offer health
insurance; compliance with quality standards established in
the law, including required quality data reporting, quality improvement strategies, and enrollee satisfaction surveys, all of which will be addressed in future regulations;
offering at least one qualified health plan at the silver and gold benefit levels;
TX
FL
NMGA
AZ
CA
WY
NV
AK
OK
MSLA
MT
TN
Status of State Legislation to Establish Exchanges,as of July 2011
Source: National Conference of State Legislatures, Federal Health Reform: State Legislative Tracking Database. http://www.ncsl.org/default.aspx?TabId=22122; Commonwealth Fund Analysis.
WA
ORID
SD
ND
MNWIWI
MI
IA
AR
IL
OH
WVVA
AL
PA
NY
ME
MA
NHVT
HI
Legislation signed into law post passage of ACA
Legislation passed one or both houses
Governors have pursued/considering non-legislative options
Legislation signed: intent to establish an exchange, creation of study panel, creates an appropriation
Legislation pending in one or both houses
UT CO
KS
NEIA
MO
ILIN
KY
WVVA
NC
SC
DC
MDDE
NJ
CTRI
Governor veto or decision not to establish exchange
State exchange in existence prior to passage of ACA
Pending legislation failed
What are Our OptionsWe can runWe can hideWe can retireWe can complainBut – There will be changes in the Healthcare
Delivery System
Here’s an OptionWhat patients and doctors need is a U.S.
government Web site run by an enlightened, well-intentioned policy elite that studies various treatments for the same condition and compares their performance. That’s how we can find effective, less costly care.”
July 4, 2011 Birmingham NewsFroma Harrop is a member of The Providence
(R.I.)Journal’s editorial board and a syndicated columnist.
Can an Enlightened, Well Intentioned, Elite Group
Design One Plan to Fit All?
Can the Government (Federal or State), Employers (the current primary insurance coverage purchasers), Payers (Medicare or Private), or any other one group design one plan to fit all?
“The barrier to change is not too little caring; it is too much complexity.”
-Bill Gates
THE COMMONWEALTH
FUND
THE COMMONWEALTH
FUND
Medicare Cost Data
2007 Medicare Beneficiary Cost and Readmission RateLouisiana - $9,500 and 22 day readmission
rateWest Virginia - $7,600 and 23 day
readmission rateAlabama - $7,600 and 17.5 readmission rateVermont - $7,400 and 14.5 readmission rateOregon - $6,100 and 13 day readmission rate
Rhode Island - $8,600 and 18.5 day readmission rate
Cost and Readmission Rate RangesLouisiana $9,500West Virginia 23 day readmission rateOregon $6,100Oregon 13 day readmission rate
The Usual, but Real, Data
Achieving SavingsThere are three basic ways to reduce Medicare and Medicaid spending: •cutting eligibility or benefits—that is, reducing the number of people, the range of services, or the share of spending covered by the programs; •trimming payments by reducing the prices paid for covered services; or reducing utilization of services. •While the third way is sometimes disparagingly referred to as rationing, there is a significant body of research showing that when patients receive the right care for their condition, and in the right amount, we can not only reduce the total cost of treatment but also improve access, quality, and outcomes.5
THE COMMONWEALTH
FUND
THE COMMONWEALTH
FUND
Those are the options facing us if we (as providers) don’t accept the challenge of working with all of the above on data driven plans that include cost and quality.
Option Three Depends on Real Data that Requires a Number
of Sources and Results in Some Providers Changing, or
Being Left Out
The Financial IssuesDefine cost effective
Comparison to the current fee for service / transaction based model? This is the initial policy under the ACO model
Long term model?How do you find out
Payers BCBS and others have great information but
difficulties in accessing it in a usable formData sources
Independent sources have data but it is blinded by individual patient name
The Quality IssuesThe Accountable Care Organization (ACO) Quality
Performance MeasuresInitial 65 quality measuresThe measures are divided by five “domains” that are
weighted equally:
Patient/Caregiver Experience (7 measures) Care Coordination (16 measures, including transitions of care and HIT) Patient safety Preventative Health At Risk Population/Frail elderly Health (31 measures) on the following
Diabetes, Heart Failure, Coronary Artery Disease, Hypertension, Chronic Obstructive Pulmonary Disease, Frail Elderly
Scoring of Quality PerformanceProviders are scored on their overall achievement
relative to a national or other benchmarkQuality performance standards will be issued in future
rulemakingPerformance Scoring
CMS sets benchmarks at beginning of each reporting year using FFS, Medicare Advantage or data it has modeled
Points are assigned to each measure (and summed by domain) based on performance related to the national benchmark.
There is a maximum of 2 points per measure, with a maximum of 130 points for 65 measures
Domain scores are determined by dividing the actual points by the maximum potential points to determine a % of performance
The 5 domain scores are averaged to determine the overall score
So, If We See Traction on Alternative Delivery
Systems, and We Will, We Are Going to Be Faced
with Getting from Here:
Cardiologist
CT Surgeon
CT Surgeon
Hospital B
Hospital C
Hospital A
Mobile Diagnostics
Interpreter A
Interpreter B
PCP
Sample Referral Decision Tree
Diagnostics
Medical Treatment
Cath
Cath
To Here:
Cardiologist
CT Surgeon
CT Surgeon
Hospital B
Hospital C
Hospital A
Mobile Diagnostics
Interpreter A
Interpreter B
PCP
Sample Referral Decision Tree - Modified
Diagnostics
Medical Treatment
Cath
Cath
And the New Decision Tree Must be Based On:
CostQuality
What do Providers NeedInformation
Keeping track of the rulesUnderstanding modelsOrganization
SystemsEMR’sReal medical record data sharing
RealityThere will be those who don’t get to
participate
What’s Out there now for Patients, Payers and
Providers
Robert Woods Johnson FoundationComparative Healthcare Quality: A National
DirectoryJune 28, the RWJF “launched the nation's most
comprehensive online directory for patients to find reliable information on the quality of health care provided by physicians and hospitals in their community.”
“Data on the performance of healthcare providers helps patients take a more active role in managing their healthcare because it lets them see what proper care looks like and whether local hospitals and physicians are delivering it.
Data Research Results http://www.rwjf.org/pr/product.jsp?id=71857
Other Information Sourceshttp://healthcarequalitymatters.org/?p=fqchttp://www.checkbook.org/patientcentral/?cb
=hmct&ref=www.healthgrades.com
Sample Using Real DataA hospital in Alabama25 primary care physiciansReferral to cardiologists based on top
diagnosesMedicare data used available through
Freedom of Information ActHPI information scrubbed
BCBS Patient Satisfaction and Quality Measures for Selected Cardiologists
BCBS AlabamaPhysician Number
% of Patients Would Recommend
Patient Satisfaction Overall # Patients Rating Diabetes Management Heart Disease
1 76% 2 37 3 22 96% 3 26 3 33 97% 3 37 2 24 97% 3 59 2 25 94% 3 16 2 36 94% 3 51 3 37 85% 3 26 2 38 96% 3 26 2 29 100% 3 17 3 3
10 98% 3 40 2 211 87% 3 23 N/A N/A12 93% 3 27 3 213 100% 3 22 2 114 95% 3 42 3 315 92% 3 37 2 N/A16 90% 3 31 2 217 96% 3 23 2 2
Healthgrades Patient Satisfaction Measures for Selected Cardiologists
Healthgrades
Physician Number % of Patients Would Recommend HG Overall of 5 # Patients Rating
1 83% 4 5
2 100% 4.5 93 100% 4.5 5
4 100% 5 15 N/A 3 36 100% 5 17 100% 4.5 1
8 100% 5 2
9 86% 4.5 5
10 83% 4.5 6
11 100% 4.5 4
12 100% 5 213 100% 5 114 N/A N/A N/A
15 N/A 2.5 1
16 N/A N/A N/A17 100% 5 6
What about the Financial Side of Things
ICD9 Diagnosis CodesEffective Year: 2010(5)Category: (CUSTOM) TOP FIVE CARDIOLOGY
DIAGNOSES(5)4011 - Essential hypertension, benign41400 - Coronary atherosclerosis of unspecified type of vessel,
native or graft41401 - Coronary atherosclerosis of native coronary artery42731 - Atrial fibrillation78650 - Chest pain, unspecified7/26/2011 ©RealTime Medical Data (205) 941-1211
[[email protected]] 00:00:09.1553124 Page 1 of 1 The Source for Timely and AccuratePaid Medicare Claims Data™
CY MGMA 2010 Cost per Physician for Top Five PDX Total InPatient Discharges(DRGs) by PrincipalDx then Physician and Major Diagnostic Categories(MDCs)(1).xls
Coronary Atherosclerosis of Native Coronary Artery
Discharge To:
Physician Number ALOS CMI Volume
Average Payment
Actual Payment
Home or Self Care Rehab
Home Health SNF Expired
1 1.94 2.342 17 $ 11,365 $ 193,034 15 1 1 0 0
2 1.58 1.733 12 $ 8,714 $ 104,562 12 0 0 0 0
3 1.75 2.109 12 $ 10,845 $ 130,140 12 0 0 0 0
4 3.45 2.622 11 $ 9,592 $ 105,507 10 1 0 0 0
5 3.55 2.783 11 $ 11,171 $ 122,877 10 0 1 0 0
6 4.9 3.422 10 $ 16,552 $ 165,517 8 1 1 0 0
7 2.78 2.79 9 $ 13,787 $ 124,084 8 0 2 0 0
8 1.25 1.776 8 $ 8,793 $ 70,340 8 0 0 0 0
9 2.38 2.277 8 $ 8,948 $ 71,585 7 0 0 1 0
10 2.25 2.455 8 $ 12,702 $ 101,616 8 0 0 0 0
11 5.29 2.963 7 $ 15,568 $ 108,978 6 0 1 0 0
12 4.57 3.03 7 $ 11,210 $ 78,469 6 1 0 0 0
13 6.83 3.941 6 $ 6,480 $ 38,878 6 0 0 0 0
14 4.25 1.578 4 $ 5,110 $ 20,441 4 0 0 0 0
15 6.75 4.941 4 $ 19,914 $ 79,655 3 0 1 0 0
16 14 9.937 3 $ 7,543 $ 22,629 2 0 0 0 1
17 2.33 1.573 3 $ 4,312 $ 12,935 3 0 0 0 0
Ranking system5 to 1 point(s) for high to low volume5 to 1 point(s) for low to high LOS5 to 1 point(s) for high to low CMI5 to 1 point(s) for low to high cost5 to 1 point(s) for high to low BCBS Patient
SatisfactionPoints totaled and physicians ranked high to
low
Coronary Atherosclerosis of Native Coronary Artery Ranking
Discharge To:
RankPhysician Number ALOS CMI Volume
Average Payment Actual Payment
Home or Self Care Rehab
Home Health SNF Expired
1 3 1.75 2.109 12 $ 10,845 $ 130,140 12 0 0 0 0
2 2 1.58 1.733 12 $ 8,714 $ 104,562 12 0 0 0 0
2 4 3.45 2.622 11 $ 9,592 $ 105,507 10 1 0 0 0
2 13 6.83 3.941 6 $ 6,480 $ 38,878 6 0 0 0 0
3 10 2.25 2.455 8 $ 12,702 $ 101,616 8 0 0 0 0
4 5 3.55 2.783 11 $ 11,171 $ 122,877 10 0 1 0 0
4 9 2.38 2.277 8 $ 8,948 $ 71,585 7 0 0 1 0
5 1 1.94 2.342 17 $ 11,365 $ 193,034 15 1 1 0 0
5 8 1.25 1.776 8 $ 8,793 $ 70,340 8 0 0 0 0
6 6 4.9 3.422 10 $ 16,552 $ 165,517 8 1 1 0 0
6 15 6.75 4.941 4 $ 19,914 $ 79,655 3 0 1 0 0
6 17 2.33 1.573 3 $ 4,312 $ 12,935 3 0 0 0 0
7 7 2.78 2.79 9 $ 13,787 $ 124,084 8 0 2 0 0
7 16 14 9.937 3 $ 7,543 $ 22,629 2 0 0 0 1
8 12 4.57 3.03 7 $ 11,210 $ 78,469 6 1 0 0 0
10 11 5.29 2.963 7 $ 15,568 $ 108,978 6 0 1 0 0
11 14 4.25 1.578 4 $ 5,110 $ 20,441 4 0 0 0 0
Atrial Fibrillation
Atrial Fibrillation Ranking
Now WhatIf I’m a specialist and highly ranked, I find
the way to get the word out to referring doctors and payers
If I’m a specialist and ranked low, I find out why and work to change or get better information
If I'm primary care, I let the specialists know I need this information in the future
What can we (Providers) Do Today?Start gathering data internallyAs Primary Care Physicians ask for quality and
cost data from our specialistsAs Specialists, be proactive in gathering the
necessary data and providing it to our PCP’sAs organizations, find out data sources,
communicate this information to our members and help our members understand the information (MASA, MGMA research?)
Work with payers when the opportunity presents itself for meaningful analysis of information
The Role of Electronic RecordsIn May, the federal government awarded its first
payments to physicians who successfully demonstrated that they are making meaningful use of electronic health record systems (EHR). To qualify for the payments, physicians had to prove that—among other things—their EHR systems were capable of capturing and exchanging health information on patients, including lists of medications, allergies, and test results. Physicians were also required to demonstrate that the EHR had the functionality for computerized physician order entry, electronic prescribing, and reporting of clinical quality measures to state and federal bodies.
The Role of Electronic RecordsReality, we cannot get the information we
need through paper chartsWe have to have discrete, searchable data
elementsWe have to have dashboardsWe have to efficiently communicated reports
and dataWe have to share information, appropriately