Incenting Quality Improvement Across 150 Canadian (Ontario) … · 2011-03-21 · Incenting Quality...
Transcript of Incenting Quality Improvement Across 150 Canadian (Ontario) … · 2011-03-21 · Incenting Quality...
Large Scale P4PLarge Scale P4PIncenting Quality Improvement Across 150 Canadian (Ontario) Hospitals
. 1 .
Introductions
Joshua Lawson
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Partner at SECOR Consulting
•
Head of the Health and Life Sciences practice
Joshua Lawson
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Partner at SECOR Consulting
•
Head of the Health and Life Sciences practice
Jonah Peranson
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Manager at SECOR Consulting
Jonah Peranson
•
Manager at SECOR Consulting
. 2 .
Vancouver
New York
MontréalToronto Paris
Québec
About SECOR
Over 35 years of experience advising companiesSECOR has become the largest international strategy boutique in Canada
Why SECOR?We integrate the organizational reality of companies and institutions into the development of action plans in order to help our clients achieve high performance.
A unique approach recognized for its impact on the growth and performance of our clients
1975
Montreal
1997
Paris
2000
Toronto
2010
Vancouver
Offices from Montreal to Vancouver, and New York, SECOR has grown significantly
2007
New York
. 3 .
Objectives
To discuss the use, design and implementation of a large-scale P4P
initiative in the Canadian context
To discuss the use, design and implementation of a large-scale P4P
initiative in the Canadian context
. 4 .
Agenda
The Context Brief overview of the Ontario health system
The Issue Hospital inpatient care
The Design Process and strategy for P4P program design
The Program Elements, results and evaluation of the program
. 5 .
Government Health Expenditures $50.2 billion
Patients 12.5 million
Physicians 24,000
Hospitals 170+
Hospital Discharges 1 million
Emergency Department Visits 5 million
Ontario OverviewOntario can be considered to one of the largest HMOs
in the
world
Source: MOHLTC, CIHI NHEX, 2010
. 6 .
Health Spending in Ontario
Total Health Spending$74.7 billion
Private Sector32.6%
Provincial Government62.8%
•
Vision Care•
Dental
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Drugs (not seniors)•
Alternative medicine
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Some long term care and home care
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Physicians
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Hospitals
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Regional Health Authorities
Other Public Sector4.4%
•
Municipal
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Federal Direct
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Workers Comp
Source: CIHI NHEX, 2010
Roughly 70% of total health spending comes from public sources and this ratio has been steady over time
. 7 .
System Structure and AccountabilityOntarians receive universal health care coverage, delivered by independent institutions and providers in 14 regions
Provincial governments are strictly funders of the health care system
Each of the 14 planning regions has its own board of directors
Each of the 170+ hospitals has its own board of directors
The 24,000 physicians participate in the corporate practice of medicine – they are not “employees”
. 8 .
Physician Payment Models
General Practitioner/Family Physician
48%73%
Medical specialist
42%58%
Surgical specialist
62%82%
20071990
Source: 1990 to 2002 CMA Physician Resource Questionnaire; 2004 & 2007 National Physician Survey (CFPC, CMA, RCPSC)
In Ontario, 65% have blended capitation and many participate in Preventative Care Management P4P incentives
Also from salary, sessionals and service contracts
There is a mixed bag of payment models, with FFS still quite prevalent
Percent of Canadian physicians remunerated 90%+ by fee-for-service
. 9 .
Agenda
The Context Brief overview of the Ontario health system
The Issue Hospital inpatient care
The Design Process and strategy for P4P program design
The Program Elements, results and evaluation of the program
. 10 .
Every patient admitted to an Ontario hospital has a MRP
Physicians of any specialty with hospital privileges can be a MRP
MRPs play a key coordinating role of patient care in the hospital
Hospital Inpatient P4PThe Ontario government established a P4P incentive to improve the performance of Most Responsible Physician care in the hospital
Day 1
Illustrative example of patient stay in hospital
• Care Management• Bedside Care• Quality and System Improvement• Patient education, and other activities
MRP
Episode of Hospital Care
Consultant
• Diagnoses• Procedures• Other activities
Patient
Admission Day 3Day 1 Day n DischargeDay 2
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Opportunity for ImprovementThe motivation for the P4P program was a realization that a small number of patients were using a huge proportion of system resources
69%69%72%73%74%77%77%77%78%78%81%81%84%85%
Planning Area
Average
NMLKJIHGFEDCBA
Source: DAD 2006/07 M7, Secor Analysis
These patients were 'stuck' in hospital because of a lack of coordinated care and they were contributing to ED wait times
Percentage of Alternate Level of Care Bed-days Occupied by High-needs Inpatients
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Key Characteristics High-needs Inpatients
Non High-needs Inpatients
Age 75+ 53% 24%
Unattached to Primary Care Physician 52% 29%
MH/Add. co-morbidity 27% 7%
Medical diagnosis 70% 59%
As a group, these high-needs inpatients need general medical, non-specialized, coordinated care
High-needs Inpatient Characteristics
Source: DAD 2006/07 M7, Secor Analysis
. 13 .
By realizing small improvements in the utilization by high-needs inpatients, we free up resources for other patients
Reduction in Avg Bed Days for High-needs
Inpatients
Adjusted Avg LOS for High-
needs Inpatients
Freed Inpatient Days
# of Non High-needs Inpatients
(Assuming 6.3 Days per Patient)
0% 72.9 0 05% 69.3 5,104 809
10% 65.6 10,209 1,61915% 62.0 15,313 2,428
Reducing bed days used for high-needs
inpatients…
…results in freeing up beds for… …other patients
ILLUSTRATIVE
Potential Benefits
. 14 .
Agenda
The Context Brief overview of the Ontario health system
The Issue Hospital inpatient care
The Design Process and strategy for P4P program design
The Program Elements, results and evaluation of the program
. 15 .
P4P Framework
MeasuresQuality■Structure and
Infrastructure■Process and
management■Outcomes
Efficiency■Productivity■Cost savings
Basis for RewardMeasurement method■Absolute level of
measure■Change in measure■Relative ranking
RewardFinancial■Bonus payment
Non-financial■Publicize measures
and rankings
We approached the P4P design using the following framework
Source: Adapted from Dr. Richard Scheffler, UC Berkeley, 2010
. 16 .
The Ontario Government negotiated a $33 million P4P platform for MRP care with the Ontario Medical Association
MRP P4P Fund
An Expert Panel of hospital executives, physicians and researchers was established to make recommendations for implementing the fund
Measures –Key indicators: average length of stay, “may not require hospitalization”
rates, and readmission rates
–Effective management
of hospital inpatientsKey Terms of P4P Platform
–
$33 million of funding over 2 yearsReward
Basis for Reward –Paid to MRP Physician Groups
to meet targets 3
1
2
Source: 2008 Ontario Physician Services Agreement
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Effective ManagementInstituting programmatic MRP care can improve efficiency without
negatively impacting health outcomes
5043
4032
29 291
847
Provider Satisfaction
Patient SatisfactionMortality
Readmission Rate
Length of Stay
Hospital Cost
000275
Improvement
No Change
Deterioration
*All studies not accounted for in the table above had either had inconclusive or no data for the relevant category
Operational Clinical Experiential
Num
ber of Studies*
57 peer-reviewed studies on effective inpatient care were analyzed
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Source: SECOR analysis
Evaluative Framework
. 18 .
Effective Management - BenchmarkingBenchmarking was conducted to identify the state of programmatic
MRP care across Ontario
Service DeliveryGovernance Performance
The degree programmatic was evaluated across three dimensions: governance, service delivery and performance
WorkloadCoverageScope of practiceIntegration
Compensation and incentivesReview processesQuality improvement
Org structureLeadershipRoles and responsibilities
1
. 19 .
1 2 2
2
11
3 2 2
3
2 2
3 3
4
3 3
11
1
Hospital
Performance andIncentives (out of 4)
Service Delivery(out of 4)
Governance(out of 5)
20
12
4
5
19
11
4
4
18
9
1
4
17
9
3
3
16
9
3
3
15
8
2
4
14
7
2
3
13
7
3
1
12
7
1
4
11
6
1
3
10
6
3
9
6
2
3
8
6
1
4
7
6
2
2
6
32
5
31
4
31
3
3
1
1
2
21
1
2
1
Effective Management - FindingsThe benchmarking showed a substantial amount of variability in the state of programmatic care across Ontario
1
Source: MOHLTC
Results of Programmatic Care Benchmarking (out of 13)
. 20 .
Key IndicatorsGiven the variability and short time horizon, realizing progress
on
small needle metrics was more likely than on big needle metrics
ED Wait Times for Admitted Patients
Length of Stay
Readmission Rates
Patient Satisfaction
PerformanceMetrics
ED Wait Times for Admitted Patients
ED Wait Times for Admitted Patients
Length of StayLength of Stay
Readmission Rates
Readmission Rates
Patient Satisfaction
Patient Satisfaction
PerformanceMetrics
←Timely medical reconciliation
←Lack of coordination ←Lack of skills
←Cognitive←Financial←Social
←Risk assessment←Lack of optimal care paths←Lack of benchmarks
←Accurate←Timely
←Standardized←Complete
Example Small Needle Metrics for Readmission Rates
MRP P4P Big Needle Metrics
Population Mgmt
Information Mgmt
Care Mgmt Patient Self- Mgmt
2
. 21 .
A volume measure was used to define physician eligibility for groups
Number of MRP services
Num
ber o
f P
hysi
cian
s
Source: CHDB 2007/08 M7, Secor Analysis
1 to 249 250 to499
500 to749
750 to999
1,000 to 1,249
1,250 to 1,499
1,500 to 1,749
1,750 to 1,999
2,000 or more
0
500
1000
1500
2000
2500
8%20%
33%
46%54%
61% 66% 71%
100%
0%
50%
100%
Cum
ulative D
istribution of M
RP
Services
Defining MRP Groups
Using an eligibility criteria helped define terms of governance for MRP groups and increase average payout from the fund
BAR GPBAR SurgeryBAR OtherBAR General Internal MedicineBAR Other Internists
LEGEND
BAR Paediatrics
BAR GPBAR SurgeryBAR OtherBAR General Internal MedicineBAR Other Internists
LEGEND
BAR Paediatrics
3
EligibilityILLUSTRATIVE Distribution of MRP Service Volume
. 22 .
Key Principles for MRP P4P DesignThe MRP Expert Panel provided the following advice on the design
of the P4P program
A one size fits all approach will not work
for the P4P design
Try to achieve progress on small-needle metrics
Give local groups the flexibility
Performance metrics should align to areas that are within the physicians’control
Advice of MRP Expert Panel
Use volume targets to define eligibility and
funding levels at each hospital
Total funding to each group should proportional to the volume of MRP services provided at the hospital
31 2
. 23 .
The Context Brief overview of the Ontario health system
The Issue Hospital inpatient care
The Design Process and strategy for P4P program design
The Program Elements, results and evaluation of the program
Agenda
. 24 .
Core Program Elements
1.
Physicians voluntarily sign up for MRP Groups
(one group per hospital corporation) and appoint a leader
2.
Physician Groups commit to ensure 24/7/365 coverage
for
unscheduled inpatients
3.
Physician Groups review performance on key indicators
4.
Physician Groups develop and begin implementation of hospital approved quality improvement plans
1.
Physicians voluntarily sign up for MRP Groups
(one group per hospital corporation) and appoint a leader
2.
Physician Groups commit to ensure 24/7/365 coverage
for unscheduled inpatients
3.
Physician Groups review performance on key indicators
4.
Physician Groups develop and begin implementation of hospital approved quality improvement plans
MRP P4P ProgramThe final MRP P4P program design has 4 main elements
. 25 .
Timeline of Activities
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Year 1 Year 2
Appoint Lead
Sign up for Groups
Define and Review Performance Indicators
Develop Quality Improvement Plans
Implement Quality Improvement Plans
Report Progress to Ministry
Activity
MRP P4P High-Level Timeline
The P4P program is being rolled out over 18 months
The first year is focused on organization and planning, while the second year is focused on implementation and reporting
. 26 .
Results to date
Early ResultsData is still being compiled and is meant to be used for illustrative purposes only
The first year of the incentive is nearing completion – participation has been strong
More than 3600 physicians across 104 hospitals have voluntarily signed up to participate
97.3% of all eligible MRP services are covered by the Groups
$10.7 million will be distributed in year 1
Median MRP group allocation of $67,000 (range from $1000 to $470,000)
. 27 .
Potential Barriers and SupportA needs assessment was conducted to determine barriers and supports required for successful implementation
Stated Support Needs
Primary■Best practice care for specific
clinical conditions■ Identifying areas for
improvement
Secondary■Change management■Writing effective QIPs■ Lean process■ Leveraging data tools
Identified Barriers to Success
Primary■Time commitment required■Cooperation amongst multi-
disciplinary members of the group
Secondary■ Level of incentive■Cooperation of other hospital staff■Relationship with hospital
administration
. 28 .
Networking and coaching facilitate knowledge sharing
Leaders will be provided with basic QI Lean Training
Example QIPs were provided to provide guidance and to set standards for the QIP deliverable
Support Program
Support for MRP P4P Incentive
Peer Support
QI Resources
Theory & Primer
Measurement tools
QIP Templates
Objective
QIP Templates
Resources
Peer Support
Timelines
Owner
Activities Desired Outcomes
Best PracticesFocusedBroad
The Ministry is now developing a support program for this initiative
UN
DE
R D
ISC
US
SIO
N
. 29 .
Assessment Against Framework
Measures
Quality■QIP planning■24/7/365 coverage■Key indicator review
Efficiency
■
Volume-based eligibility criteria
Basis for Reward
Method of Measurement■
Approval of QIP
■
Reporting on performance review
Reward
Financial
Bonus payment distributed from allocation of $33 million over 2 years
Self- Evaluation
Areas for Improvement
Outcome metrics are not considered
Measurement is binary rather than relative
Funding is time- limited with no
guaranteed for continuation
Program Element
. 30 .
Next StepsThe Ministry is taking steps to spread MRP best practices across
the sector and formalize programmatic care for the future
TodayJuly 2011
Online Toolkit QIP Review Networking and Coaching
2012 Negotiation
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Review the hospital-
approved MRP Group QIPs
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Develop resource of tools, templates and best practice interventions
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Facilitate forums for peer-
learning, collaboration and knowledge sharing
March 2012
November 2011
June 2011
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Prepare recommendations for models of care and HHR strategy
. 31 .
Questions?
Joshua Lawson
•
Partner at SECOR Consulting
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Joshua Lawson
•
Partner at SECOR Consulting
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Jonah Peranson
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Manager at SECOR Consulting
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Jonah Peranson
•
Manager at SECOR Consulting
•