Better care at less cost - a 'how to' for commissioners and providers, pop up uni, 11am, 3 september 2015

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Better care at less cost – a ‘how to’ for commissioners & providers

William E. Golden, MD, MACP Nena Sanchez, MS, PMP

Ben Breeze

Introduction

Ben Breeze

UK Healthcare Director

General Dynamics Health Solutions

Yesterday

Similar reform initiatives over

many years in UK and US

Costs increasing year on year

Need for a ‘self reforming’ system

Incentivising quality, reduce cost

and improve outcomes

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We talked about the ‘WHAT’

Today

Quick recap

How to approach a quality

incentive programme

Setting up and running the

programme

Results

Applying this to the UK


Is about ‘HOW’

Programme Overview

William E. Golden, MD, MACP, Medical Director

Arkansas Department of Human Services

Division of Medical Services

Same challenge

Improving the experience of

care

Improving the health of

populations

Reducing the per capita

costs of healthcare

Triple Aim Five Year Forward View


Care and quality gap

Health and wellbeing gap

Funding and efficiency gap

Similarities of public healthcare

Providers Providers

NHS

England

Wales

Scotland

NI

CCGs

Patients Patients

Everyone

Over 65 Registered disabled Children Low income

State

Medicaid

State

Medicare

Center for Medicare & Medicaid

£

T

a

x

e

s

$

T

a

x

e

s

Department of Health &

Human Services Department of Health


Perspective: grading a physician’s value


Measure attributes


Reliable

Low Burden

Actionable

Feasible Meaningful (importance)

Outcomes & Lessons

Stretch the Providers Who…

Provide Programme Feedback…

That Modifies Requirements/Analytics…

Which Support Practice Transformation…

And Starts New Cycle of Dialogue


Learning System

The need for a ‘self reforming’ system

GDIT Proprietary

Efficiencies at the price of lost

funding or downsizing the

organisation are a ‘hard sell’

Incentivising the right

behaviours does lead to

change, e.g. QOF programme

for UK GPs

Positive change in the clear

interests of the organisation

happens much faster

The financial system must

support clinical priorities, or

at least not be in direct conflict

Rewarding quality leads to

higher quality

11 | www.uk.gdit.com/health

Terminology

Same as episode in the UK, however these were developed as part

of the payment improvement initiative.

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Episode

Medicare

Medicaid

PaP

Payer

PCMH

Provider

Publicly funded care for the over 65s and registered disabled (20%

of overall health spend).

Publicly funded care for those on low incomes (15% of overall health

spend). A high percentage of recipients are children. The Arkansas

Health Care Payment Improvement Initiative focuses on Medicaid.

Primary Accountable Provider, read as Provider.

Insurer (public or private) who funds the treatment being given.

Similar to a CCG or Social Services in the UK.

Patient Centred Medical Home; a delivery model where care is

coordinated by the primary care physician supported by technology.

Same as UK, organisation delivering the care.

Episodes

Episodes have the potential to …

As in the UK, episodes were used to

organise the delivery of care


Avoid complications, reduce errors and redundancy

Deliver coordinated, evidence-based care

Focus on high-quality outcomes

Improve patient-focus and experience

Incentivise cost-efficient care

This new approach enhanced the existing ‘fee for

service’ model

Pay for results to control costs and improve quality


Eliminate coverage of expensive services, or eligibility

Pass growing costs on to consumers through higher

premiums, deductibles and co-pays (private payers), or

higher taxes (Medicaid)

Intensify payer intervention in clinical decisions

to manage use of expensive services (e.g. through prior

authorisations) based on prescriptive clinical guidelines

Reduce payment levels for all providers regardless of

their quality of care or efficiency in managing costs

Transition to system that financially rewards value and

patient outcomes and encourages coordinated care

Three domains of care


Patient populations within scope (examples) Care/payment models

Population-based: medical homes responsible for care coordination, rewarded for quality, utilisation and savings against total cost of care

Episode-based: retrospective risk sharing with one or more providers, rewarded for quality and savings relative to benchmark cost per episode

Combination of population- and episode-based: health homes responsible for care coordination; episode-based payment for supportive care services

Healthy, at-risk

Chronic (Diabetes)

Acute medical (Pneumonia)

Acute procedural (hip replacement)

Developmental disabilities

Severe and Persistent mental illness

Acute and

post-acute care

Prevention screening,

chronic care

Supportive care

Episodes designed in collaboration with providers


Cli

nic

ian

s a

re in

teg

ral t

o t

he

epis

od

e d

esig

n p

roce

ss

Research around national guidelines and standards of care

Clinical Advisors provide input for localisation of practice patterns and inform the process about the patient journey

Programmers

and Coders create algorithms and logic to implement design elements

How episodes work for patients and providers


seek care

& select

providers as

they do today

submit claims as

they do today

reimburse for all

services as they

do today

Patients seek

and providers

deliver care

exactly as

today

(performance

period)

Patients Commissioners Providers

Shared savings

Shared costs

No change

Low

High

Individual providers in order from highest to lowest average cost

Acceptable

Commendable

Gain

sharing limit

Pay portion of

excess costs

No change in payment

to providers

Receive additional payment

as shared savings

Quality standards and average costs share in savings

GDIT Proprietary

+

-


Mechanics, Technology &

Data Reporting

Nena Sanchez, MS, PMP

Senior Director of Programs

General Dynamics Health Solutions

Operationalize plan – data-to-episode outputs


Input Data

Files

EOC Engine (Report Calculations)

Report Engine (Report Production) Payment

Providers Reports

Call Centre Reports

Statistical Reports

Episode Based Payment System (EBPS) follows a modular design that is maintained in such a manner that it will align business, architecture and data

Providers given tools to measure & improve care


Example of provider reports Reports provide

performance information

for provider episode(s):

Overview of quality across a provider’s episodes

Overview of cost effectiveness: how a provider is doing relative to cost

thresholds and relative to other providers

Overview of utilisation and drivers of a provider’s average episode cost

6

10,625

433

1,062

1,400

1,251

2,260

944

1,321

1,307

1,237

3,409

3,865

9,492

643

Cost detail – Pharyngitis

Care

category

All providersYou

51%

49%

3%

5%

5%

7%

11%

9%

77%

79%

97%

95%

52%

48%

81

51

59

2,500

3,000

600

500

1,062

179

62

1,400

81

194

69

Medicaid Little Rock Clinic 123456789 July 2012

Total episodes included = 233

Outpatient

professional

Emergency

department

Pharmacy

Outpatient

radiology /

procedures

Outpatient

lab

Outpatient

surgery

Other

89

77

221

184

21

16

12

# and % of episodes

with claims in care

categoryTotal cost in care

category, $

Average cost per

episode when care

category utilized, $

5

Quality and utilization detail – Pharyngitis

5025

PercentileMetric You 25th

Metric with a minimum quality requirement

You did not meet the minimum acceptable quality requirements

Metric 25th 50th

50th 75th

You 75th 5025

Percentile

You

Percentile

Percentile


0

0

100

100

Minimum quality requirement

30% 5%% of episodes that had a strep

test when an anti-biotic was filled

% of episodes with at least one

antibiotic filled64% 44%

% of episodes with multiple

courses of antibiotics filled6% 3%

81%

60%

10%

99%

75%

20%

Average number of visits per

episode1.1 1.31.7 2.3

-

-

-

Quality metrics: Performance compared to provider distribution

Utilization metrics: Performance compared to provider distribution

75

75

4

Summary – Pharyngitis

Quality summary

182345

80

292315

100

50

>$115$100-

$115

$85-

$100

$70–

$85

$55–

$70

$40-

$55

$40

You

(adjusted)

20,150

You (non-

adjusted)

25,480

80

60

40

8184

All providersYou

Cost summary

Your total cost overview, $

Distribution of provider average episode cost

Your episode cost distribution

Average cost overview, $

Not acceptableAcceptableCommendableYou

Minimum quality requirement

All providers

Key utilization metrics

Overview

Total episodes: 262 Total episodes included: 233 Total episodes excluded: 29

Does not meet minimum quality requirements

You did not meet the minimum quality requirements Your average cost is acceptable

You are not eligible for gain sharing

Quality requirements: Not met

Average episode cost: Acceptable

# e

pis

odes

Cost

, $

You All providers

Commendable Not acceptableAcceptable$0


% episodes withstrep test when

antibiotic filled

48%

Quality metrics – linked to gain sharing

66%

58%

10%

6%

64%

Quality metrics – not linked to gain sharing

% episodes with

multiple courses

of antibiotics filled

% episodes with at least one

antibiotic filled

1.11.730%

64%

Avg number of visits per episode % episodes with antibiotics

Cost of care compared to other providers

You

Percentile

Gain/Risk share

All provider

average

< $70 > $100$70 to $100

3

Upper Respiratory Infection –

Pharyngitis

Quality of service

requirements: Not met


Sinusitis

Average episode cost:

Commendable

Quality of service

requirements: N/A

You are not eligible

for gain sharing

Your gain/risk share

You will receive gain

sharing



Non-specific URI


Not acceptable

Quality of service

requirements: N/A

You are subject to

risk sharing


Perinatal


Acceptable

Quality of service

requirements: Met

You will not receive

gain or risk sharing



Acceptable

Attention Deficit/

Hyperactivity Disorder (ADHD)


Acceptable

Quality of service

requirements: N/A

You will not receive

gain or risk sharing


$0

$x $0

$0

$x


Performance summary (Informational)

* Episode and health home model for adult DD population in development. Tools and reports still to be defined.

Example provider reports

Cost Categories: Provider vs. Peer


Provider portal


Accessible to all providers

– Login with existing username/ password

– New users follow enrollment process detailed

online

Key components of the portal are

to provide a way for providers to:

– Enter additional quality metrics for select

episodes (Hip, Knee, CHF and ADHD with

potential for other episodes in the future)

– Access current and past performance reports

for all payers where designated

Provider Portal allows providers to enter quality metrics for certain episodes and access their provider reports

Example data entry




Provider Report Displays provider-level reports for each time period that they were sent. Display supports

Health administrators and APII call center staff



Reporting


Reporting Health Officials and support staff use an application tool to view

provider reports and episode level statistical reports

meet & exceed informational needs

assist in interactions with the Health officials and GP community

Configurable elements


Configurable Elements Allows approved administrators to update algorithm specific modules

and allows Health officials to perform “what if” analysis by changing values for certain variables

Working example:

EOC Engine provides ability

to see the impact of

changing acceptable

threshold

Hip replacement costs

reduced from $12K (£7.8K)

to $10K (£6.5K)

Reports can be generated to

see the impact of the change

Data system – design feedback loop


Refine preliminary Episode of Care (EOC) algorithms by feedback and investigation Focused improvement based on relevant data and Business process.

Call Centre

Provider Relations

Data Research

Provider Engagement

EOC Refinement

Practice Pattern

Goal

Focused

Research

Findings EOC Refinement

Practice Pattern

Billing Issues

Identified the need for portal entry of QMs

Length of stay analysis showed providers with greater than 3 days due to C-section births

Now that the programme is established,

it’s time to measure the results.

EOC programme details


Since the initial release of the EOC programe in 2012:

14 quarterly EOC runs have been completed

6 payment runs have been completed, including generation of gain/risk

share payments

The Episode Engine has identified approximately 2,000 PAPs

The Episode Engine has processed over 456.4m Medicaid claims

and generated over 3.3m episodes

The Reporting Engine has generated over 26,000 PAP Reports

EOC dashboard


Highlights

Includes all data for the history of the EOC programme

Data is presented through various visualisations including:

– Trending graphs (line, bubble, bar, etc.)- provide “clear and actionable” information

– Charts

– Pivot Tables

– State-based Geomapping

Multiple views to the data in print and export-ready formats

Drill-down, action-linked functionality for over 60 quality and utilisation metrics

Data files representing all of the hundreds of thousands of data points presented in the

dashboard are available for download for the purpose of performing ad-hoc analysis on

the data using any desired analytic tool

Provides detailed documentation explaining all of the measurements, instructions on

using the dashboard, descriptions of changes to the EOCs over time, and other analytic

information in order to fully inform dashboard users

EOC dashboard


Layout

Tab navigation Time period selector

Export link

Slider to select ranges for each grouping

Chart type selector

View data in tabular format

Geomapping


% of episodes excluded by country and quarter

EOC dashboard


Example

Trending: Quality metric results URI-Nonspecific: Episodes with an antibiotic claim

EOC dashboard


Example

Provider Engagement PAP Report view counts by day per month and by provider

EOC dashboard


Example

Information: Variety of definitions, user guide and analytic notes Episode Changes Over Time documentation provides information on changes made to the

EOC algorithms to assist with explaining trends in the data

EOC dashboard


Example

Trending Gain share, Risk share by quarter (programme level)

Results: Quality of care


Results: Cost savings


UK application

What data is available now?

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What level of costing can differentiate episodes?

What data can be extracted from source systems?

What are your

local priorities?

What are the major lessons from the

programme? What opportunities does the National Tariff System bring?

What are the limitations

of current tariffs/HRGs?

Questions?

William E. Golden, MD, MACP Medical Director Arkansas Department of Human Services Division of Medical Services

Nena Sanchez, MS, PMP Senior Director of Programs General Dynamics Health Solutions

GDIT Proprietary

Please rate our workshop using the app!

For more information


Ben Breeze UK Healthcare Director

General Dynamics Health Solutions [email protected]

www.uk.gdit.com/health

Expanding Insight. Ensuring Value. Improving Outcomes.