PTE BH Objectives

• To understand Pathways to Excellence process for physician practices

• Explore how to utilize PTE process for Behavioral Health

Experience with Health Data: It is both less and more complicated than what people say.

• Maine Health Data Organization Board, 1997 to 2002, 2009 - 2013.

• Maine Health Information Center/Onpoint Board, 2003- 2010

• Maine Data Processing Board 2007-08• AHRQ Healthcare Cost and Utilization Project Steering

Committee, 2010- 2012• NCQA Committee on Performance Measurement, 2009 -

2011• National-Regional Workgroup of the Quality Alliance

Steering Committee, 2008 - present• National Quality Forum: Workgroup on Patient Reported

Outcomes Measures, 2012-13 2

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Our Quality Is Less………

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BETTER

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SWIZ

NETH

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AUS

UK

JPN

Average spending on healthper capita ($US PPP)

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USNETHFRGERCANSWIZUKJPNAUS

Total health expenditures aspercent of GDP

Notes: PPP = purchasing power parity; GDP = gross domestic product.Source: Commonwealth Fund, based on OECD Health Data 2012.

Our Costs Are MoreInternational Comparison of Spending on Health, 1980–2010

5

Adherence to Quality Indicators

10.5%

22.8%

32.7%

40.7%

45.2%

45.4%

48.6%

53.0%

53.5%

53.9%

57.2%

57.7%

63.9%

64.7%

68.0%

68.5%

73.0%

75.7%

0% 20% 40% 60% 80% 100%

Alcohol Dependence

Hip Fracture

Ulcers

Urinary Tract Infection

Headache

Diabetes Mellitus

Hyperlipidemia

Benign Prostatic Hyperplasia

Asthma

Colorectal Cancer

Orthopedic Conditions

Depression

Congestive Heart Failure

Hypertension

Coronary Artery Disease

Low Back Pain

Prenatal Care

Breast Cancer

Percentage of Recommended Care Received

Problems with UnderUse

2004: Adults receive about half of

recommended care

54.9% = Overall care 54.9% = Preventive care 53.5% = Acute care56.1% = Chronic care

Not Getting the Right Care at the Right Time

Source: McGlynn EA, et al., “The Quality of Health Care Delivered to Adults in the United States,” New England Journal of Medicine, Vol. 348, No. 26, June 26, 2003, pp. 2635-2645

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MHMC 1995

quality / outcomes + Value: change in health status +

employee satisfactionCost

Best quality health care - BBest outcomes and quality of life - DMost satisfaction - BFor the most affordable cost – D- soon to be B+For all Maine citizens - A

All Started With Depression - 1998

• Employers saw depression crop up in all benefit programs (WC, GH, STD, LTD, Abs)

• Ran EAP programs, but needed health system• 1999-2000 MHIC Led Nurse Telecare initiative

with 14 PCP practices• Improvement in med adherence, Hamilton

Scores, SF-12 scores, and Household, Work, & Leisure Time Functioning

• Productivity went up (but no one knew it), practices lost money (no one paid them), and drug costs increased

What To Do?

• Employers couldn’t just focus on one disease

• Seemed like chronic illness went together

• Started initiative focused on depression, diabetes, CVD, & asthma

• “Informing Patients & Rewarding Providers”

3 Basic Aspects of QualityType of Measure Definition Examples

Structure The opportunity exists to obtain good care.

• Right number / mix of providers. (e.g. PCP, specialists, MSW, etc.)

• Computerized Rx physician order entry

ProcessInterpersonal

Interventions are humane and responsive to patients’ preferences

• Testing/treatment choices explained• Patients get questions answered

ProcessTechnical

Interventions are provided skillfully to the people who need them

• Evidence-based guideline compliant treatment

• Right tests• Right Rx, treatments etc.

Outcomes: clinical, functional, financial

The best possible clinical and patient results are achieved.

• Normal lab values• Patients live• Symptom free days• Patients function more effectively at

work, home, and play 9

3 Basic Aspects of Quality – Rooney’s view using CPDP Criteria

Type of Measure PCPs Specialties Hospitals ACOs

StructureGood Good Good Good

ProcessInterpersonal Coming 50% Coming 25% Good Good

ProcessTechnical

Good for most

processes

Poor except Cardiology

Good for most

processesGood

Outcomes: clinical Good – 50% Poor Poor Developing

Outcomes: Functional/Pop Hlth Poor Poor Poor Developing

Outcomes:financial

Total Cost of Care/Util.

Prometheus Onpoint &/or Aetna

Total Cost of Care10

PTE Evolution - Diabetes

• 2005: Practices measuring HbA1c, BP, LDL

• 2006: Practices with measures on 85% of patients with diabetes

• 2007: Achievement of certain outcomes of care

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Pathways to Excellence – Physicians Steering Committee 2014

Practice Leaders:

• Jeff Aalberg, MD: MMC PHO• Bob Allen MD: PCHC• Michael Bergeron, MD: St. Mary’s• Frank Bragg, MD:  EMMC• Tom Claffey, MD: InterMed• Ned Claxton, MD: CMMC• Barbara Crowley, MD: MaineGeneral• Marcus Deck, MD: Bowdoin Med Gp• Rich Engel, MD: Greater Portland MG• David Howes, MD: Martin’s Point• Lisa Letourneau, MD: Quality Counts

• Jay Naliboff MD: Franklin

• Gary Ross DO: MNH, Brewer

• John Yindra MD: DFD, MCHO

Health Plans Med. Directors:• Aetna

• Anthem

• CIGNA

• Harvard Pilgrim

• MaineCare

Employers/Plan Sponsors:• Christine Burke: MEA Benefits Trust

• Chris Brawn: State Employee Health Plan

• Tom Hopkins: Univ. Maine System

• Chris McCarthy: Bath Iron Works

• Steve Gove: ME Municipal Health Trust

• Joanne Abate: Hannaford Bros.

Clinical Outcomes

Interpersonal Process

Structure-Process

2013

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MHMC 2004 Incent Patients and Providers

Quality

High

Costs LowHigh

Low

Effective & Efficient

Ineffective & Inefficient

Ineffective & Efficient

Effective & Inefficient

• Efficiency w/o Quality is Unthinkable• Quality w/o Efficiency is Unsustainable

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Health Plan - Employer Use

• State of Maine Tiered Networks–Hospital based on PTE Metrics 2006

• Waive $300 co-pay

–PCPs based on PTE 2-3 Blue Ribbons July 2007• Waive $10 co-pay and deductible on office visits

–Deductible & co-pay waiver for diabetic pilot

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SEHC Announce 7-07 PCP Tiering

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Current PTE Participation

Practices 2007 2008 % Ch

3 Blue Ribbon 131 171 + 31%

2 Blue Ribbon 59 71 + 20%

1 Blue Ribbon 70 69 -1%

0 Blue Ribbon 169 125 -26%

Maine: 2nd biggest improvement in US

Medication Survey Results 2005-2009 (as of 8-09)

2005 Total

2005 Pie

2006 Total

2006 Pie

2007 TOTAL

2007 PIE

2008 TOTAL

2008 PIE

2009 TOTAL SCORE

2009 PIE

Parkview 21 52 91 96 97

Mayo Regional Hospital 13 26 53 74 93

Down East Community Hospital 21 22 33 46 91

Miles Memorial 24 25 66 71 90

Mercy Hospital 29 33 83 96 90

Cary Medical Center 29 44 78 68 85

St. Andrews 0 2 5 63 84

Mount Desert Island Hospital 21 44 76 75 84

York Hospital 13 19 63 72 82

Stephens Memorial Hospital 19 27 65 81 81

Rumford Hospital 0 13 57 66 79

Eastern Maine Medical Center 30 25 71 79 78

Central Maine Medical Center 26 38 67 80 78

Penbobscot Bay Medical Center 13 8 54 73 78

Maine Medical Center 35 35 71 77 77

Southern Maine Medical Center 21 27 65 61 76

Blue Hill 0 21 42 67 75

Maine Coast Memorial Hospital 7 23 68 72 73

Bridgton Hospital 24 24 62 73 73

Franklin Memorial 0 29 56 50 72

Midcoast Hospital 32 35 70 74 71

MaineGeneral Medical Center 28 35 63 68 71

Sebasticook Valley 0 26 60 70 71

The Aroostook Medical Center 5 6 63 70 71

Northern Maine Medical Center 0 36 74 73 70

St. Mary's R.M.C. 23 23 44 54 68

St. Joseph Hospital 9 28 59 57 67

Inland Hospital 0 21 59 66 66

Penobscot Valley Hospital 14 31 42 57 66

Goodall Hospital 9 14 67 57 58

Calais Regional Hospital 31 38 61 54 57

Redington Fairview 18 17 36 32 52

Millinocket Hospital 0 27 52 43 52

Houlton Regional 7 12 24 25 52

CA Dean 1 1 1 34 47

Waldo County General Hospital 0 10 48 43 45

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State Employee June, 2008

• My blood sugar numbers were in 400’s. Scary!• My A1C was 9.7, now it is below 7.5What made me go:1. Not having to pay co-pays on my medications for

a year…That was incentive to get me in door2. Even with $ incentive, I wouldn’t have kept

coming back if the staff were punitive or judgmental, or had unreasonable expectations. Every staff person ….was helpful, understanding, and reasonable.

Aligning Maine’s“Forces”Consumer

Engagement

Quality Improvement

Payment Reform

Benefit Design

Promote Health IT Adoption

QC/MHMC: AF4Q Consumer Messaging/ Leadership

MHMC Employee Activation Program

MHMC : PTE reporting on hospitals, primary care, specialist quality

MPIN, PHOs: QI support to mbr practices

Hospitals/ Health Systems & Employers: Local ACO Pilots

Primary Care & Employers/Payers: Alternative payment models

Maine PCMH Pilot

BIW Primary Care Program

Specialty Care: Alternative payment models

Cognitive Consultation

MEREC: Promote primary care HER adoption, meaningful useHealthInfoNet: Promote interoperable systemsBangor Beacon: promote community-wide, connected HIT

MHMC: Encourage employer/payer use of PTE data for steering;

Value-based insurance design

Perf Meas./ Public Report MQF: reporting on hospital quality, patient

experience of care (TBD)

Quality Counts: QC Learning Community

What Contributes to Health Outcomes?

Univ. Wisconsin - RWJF County Health Rankings

Employers & Consumers Get This – But What to Do?

PCMH Practice

High-need Individual

Maine PCMH Pilot Community Care Teams

Transportation

Workplace

Environment

Food Systems

Shopping

Income

HeatFaith

Community

Literacy

Coaching

Physical Therapy

Hospital Services

Specialists

Outpatient Services

Med Mgt

HousingCare Mgt

Behav. Health & Sub Abuse

Family

Schools

Healthcare

Delivery System Change

Payment

Reform

System Transformation

Amb• Advanced

Primary Care/PCMH (New workforce: Practice RN Care Managers)

Comm

• Community Care Teams for High-Cost/High-Risk Patients (New workforce: CCT staff)

Comm

• Enhanced Care Transitions (New workforce: Hospital + Community-based Care Transition Coaches)

• Bundled Payments

• Partial

Capitation

• Global

Capitation

It’s About the Basics(the hard work!)

CMS ACO Metrics

Better Health for Individuals• CAHPS: 7 items• All cause readmission rate• Ambulatory sensitive conditions for COPD

and CHF• % PCPs qualifying for EMR incentive• Medication Reconciliation after hosp.• Screening for fall risk

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CMS ACO

Better Health for Populations• Preventive Health: 8 metrics

including depression screen• Diabetes composite: 6 metrics• Hypertension• Heart Disease: 5 metrics

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CMS ACO CAHPS

• 53. In the last 6 months, how often was it easy to get the care, tests or treatment you thought you needed?

• 57. In the last 6 months, did anyone on your health care team ask you if there was a period of time when you felt sad, empty, or depressed?

• 58. In the last 6 months, did you and anyone on your health care team talk about things in your life that worry you or cause you stress?

• 65. During the last 4 weeks, how much did your physical health interfere with your normal social activities with family, friends, neighbors or groups?

March 2014

Promis

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Focus On Behavioral Health

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Head and Heart

Money

Recognition

Right Thing