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Collaboration on Quality: A Foundation Built on Trust
Michael Pekas, M.D.Medical DirectorJoel HasenwinkelDirector, Clinical Collaboration
Wellmark Blue Cross Blue Shield 2006
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Wellmark at a GlanceWellmark Blue Cross Blue Shield of Iowa, an Iowa Mutual Insurance CompanyWellmark Blue Cross Blue Shield of South Dakota, a South Dakota Insurance CompanyWellmark Health Plan of Iowa, Inc., an Iowa HMO owned by Wellmark and Iowa ProvidersMore than 1.5 million members1 in 2 Iowans1 in 4 South DakotansIndependent licensee of Blue Cross and Blue Shield AssociationComprehensive provider network
Wellmark Blue Cross Blue Shield 2006
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Health Care CrossroadsPremium cost has increased substantially
Increased number of uninsured
No clear data that increasing costs always translate to improved care
Health care affordability is at significant risk
Wellmark Blue Cross Blue Shield 2006
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Where did Wellmark start?Focus on Patient Centered Care
Work closely with clinical community
Voluntary Program for Primary Care Physicians
Reduce Practice Variation
Encourage Improved Quality and Efficiency
Collaborate to Improve Provider Office Infrastructure
Wellmark Blue Cross Blue Shield 2006
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How did Wellmark help?Provide usable data
Supply resources to support change
Encourage process improvement
Bring all stakeholders to the table
Recognize and reward those that succeed
Wellmark Blue Cross Blue Shield 2006
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How did Wellmark start?Identified Physician Leaders in a participating clinicLeaders recruit participants Drive local activity
Participants identified relevant disease conditions for community
Aligned work with clinic initiatives and objectives
Jointly established guidelines and performance targets
Included physician care team in design
Wellmark Blue Cross Blue Shield 2006
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Encourage change agentsRecognize participating clinicians in directories Designate support resources from Wellmark
Simplify certain administrative processes
Deliver performance reports on pharmacy
Recognize publicly as performance objectives are met
Wellmark Blue Cross Blue Shield 2006
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Recognizing and Rewarding Best Practices
Mercy Clinics Perspective
David Swieskowski, MD, MBAV.P.for QualityMercy Clinics, Inc.Des Moines, Iowa
Wellmark Blue Cross Blue Shield 2006
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Mercy Clinics, Inc.Established in 1984Owned by Mercy Hospital Medical Center Non Profit23 Clinics 126 physicians668,613 patient visits in 2004Virtual Private PracticeAmbulatory Care Quality is a Board Strategic priority
Wellmark Blue Cross Blue Shield 2006
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Wellmark Blue Cross Blue Shield 2006
Chart1
8
7.7
7.7
7.77
8.12
8.53
8.45
8.31
8.28
8.26
7.94
7.73
7.68
7.8
7.87
7.67
7.75
7.81
8.15
8.12
8.01
7.61
7.78
7.64
7.32
7.66
7.61
7.5
7.47
7.41
7.88
7.88
7.45
7.45
7.47
7.18
7.29
7.26
7.22
7.36
7.21
7.35
7.44
7.14
6.97
MCI Average HgA1C Values July 98 - Mar. 02Compared to a national average of 9%. (Clinical Diabetes: V.20, No.2, 2002)
Sheet1
ClinicControl
MeanMean
May7.82
Jun7.85
Jul7.92
Aug7.64
Sep7.72
Oct7.66
Nov7.50
Dec7.69
Feb7.68
Mar7.86
Apr7.79
May7.68
Jun7.615.6
Jul-988.00
Aug7.705.6
Sep7.705.5
Oct7.775.5
Nov8.125.6
Dec-988.535.8
Jan-998.455.7
Feb8.315.6
Mar8.28
Apr8.265.6
May7.945.9
Jun7.735.9
Jul7.68
Aug7.806.00
Sep7.876.07
Oct7.675.90
Nov7.756.00
Dec-997.816.20
Jan-008.156.20
Feb8.126.02
Mar8.016.13
Apr7.615.91
May7.786.04
Jun7.645.94
Jul7.325.37
Aug7.665.50
Sep7.615.65
Oct7.505.62
Nov7.476.01
Dec-007.415.95
Jan-017.886.03
Feb7.886.05
Mar7.455.72
Apr7.455.86
May7.475.73
June7.185.75
July7.295.85
Aug7.265.76
Sep7.225.89
Oct7.365.93
Nov7.21
Dec-017.35
Jan-027.44
Feb-027.14
Mar-026.97
Sheet1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
MCI Average HgA1C Values July 98 - Mar. 02Compared to a national average of 9%. (Clinical Diabetes: V.20, No.2, 2002)
Sheet2
Sheet3
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Wellmark Blue Cross Blue Shield 2006
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Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
Improved Outcomes
Delivery SystemDesign
DecisionSupport
Clinical Information Systems
Self- Management Support
Health System
Resources and Policies
Community
Health Care Organization
Chronic Care Model
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MCI GoalsPatient Centered Care Performance measurementDisease RegistryImproved outcomesReduced costChronic Care ModelWellmark GoalsPatient Centered CarePerformance measurementClinical InformationImproved outcomesReduced costDisease managementAlignment of Goals
Wellmark Blue Cross Blue Shield 2006
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Engaging MCI Physicians
Data will be used against themBonus for high performance will evolve into a penalty for low performance Will use clinical data to take over disease management themselves
Out to game the systemWont cooperateNot capable of system improvementChoose data based on ease of collection not usefulness
BarriersResponseLack of trustPhysicians as partners in design of the programInaccurate patient listPhysician generated listFinancial disincentivesP4P & pay for Self-Management SupportDifficult to define ROISettled on pharmacy costHard to measure resultsLimited data setDesign process too longFinally just started
Wellmark Blue Cross Blue Shield 2006
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Recognize & Reward Best PracticesQuality ParametersPay for PerformanceData self-reported by providers
Wellmark Blue Cross Blue Shield 2006
Process
Goal*
Outcome
Goal*
Diabetes overall** 80% 70%
Proportion with HgA1C < 8.0 or 1% improvement over the last year (i.e. 8.6 to 7.6)
85%
70%
Proportion with LDL < or = 130
85%
70%
Proportion with BP < or = 140/90
85%
70%
Nephropathy screening or evidence of disease
70%
Documentation of Diabetes education or Patient refusal
Establish Baseline
Hypertension Quality overall** 80% 70%
Proportion with BP < or = 140/90
85%
70%
Lipids checked in last 30 months
85%
Glucose checked in last 30 months
85%
Proportion with microalbumin documented in the last year
70%
Patient education documented
Establish Baseline
Quality Incentive Payment
$
$
Pharmacy Targets*** Incentive Payment
Per member per month cost: % < Wellmark Avg.
4.0%
$
Per member per month cost: % < Wellmark Avg.
6.0%
$
Mercy Clinics, Inc./Wellmark Quality Parameters
*If a parameter is not within goal, evidence of action to achieve the goal will meet criteria.
** Overall goal is the average of all the goals in the disease suite.
*** This is a group goal paid to all or none
Process Goals are whether or not a test was done within the last year (unless otherwise stated) and can often be determined by billing data.
Outcome Goals reflect clinical measurements described in the left hand column.
April 26, 2005
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Improving Physician Quality ScoresCurrentlyDepend on physician memory and Individual effortIn the FutureWill depend more on the system physicians work in than on individual effort
Working harder is the worst plan -W. Edwards Deming
Wellmark Blue Cross Blue Shield 2006
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Delivery System RedesignDisease Registry for diabetes and HTNDiabetes Flow Sheet up to date on each chartDiabetes and Hypertension GuidelinesStanding orders for diabetes & HTN careDiabetes OV formChecklist so all critical elements are addressedCodes to a level 4 office visitLevel 4 EM visits went from 49% to 72% of total visitsPopulation Health Coaches
Wellmark Blue Cross Blue Shield 2006
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Population Health CoachFull time position in 4 clinics, part time in othersWellmark Foundation grant provided seed moneyProactively manages the populationOversees registriesCalls patients Overdue visitsNot meeting goalsPre-visit chart review for chronic care patientsPre-work saves Doctor timeProvide or arrange for education & SMSAssist with group visits
Wellmark Blue Cross Blue Shield 2006
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Physician Level Performance Reports
Wellmark Blue Cross Blue Shield 2006
9-05
SECAT Performance Reports
Campus Clinic
Sep-05
WELLMARK Diabetes Data: 9/1/04-9/1/05
ProviderHeimsKennedyMooreSteinmetzSwieskowskiGoal
Total Patients1613373011
Process goals:
HgAlc last 12 mo.100%92%95%83%100%85%
LDL last 12 mo.81%85%70%80%91%85%
SBP last 12 mo.100%100%95%87%100%85%
Microalb last 12 mo.75%62%68%80%82%70%
Overall process goal %89.00%85.00%82%83%93.00%80%
Overall process goal met?YesYesYesYesYes
Drs. Kennedy and Moore-Adjusted denominator to reflect notification intervention by the
clinics' Population Health Coach regarding care opportunities
Outcome goals:
% HgAlc < 8.088%58%66%76%90%70%
% LDL < 13077%82%81%83%90%70%
% SBP < 14081%93%80%93%82%70%
Overall outcome goal %82%78%76%84%87%70%
Overall outcome goal met?YesYesYesYesYes
SECAT Performance Reports
Campus Clinic
Sep-05
Wellmark HTN Data: 9/1/04-9/1/05
ProviderHeimsKennedyMooreSteinmetzSwieskowskiGoal
Total Patients4865707741
Process goals:
SBP last 12 mo.98%92%94%97%100%85%
Lipids last 30 mo.94%89%86%92%95%85%
Glucose last 30 mo.90%80%77%92%98%85%
Microalb last 12 mo.88%69%73%78%88% ]70%
Overall process goal %94.00%83%83.00%90.00%95.00%80%
Overall process goal met?YesYesYesYesYes
Dr. Moore-Denominator adjusted to reflect notification interventions regarding care opportunites conducted by the clinic's Population Health Coach
Outcome goal:
% SBP < 14076%75%73%79%83%70%
Overall Outcome goal met?YesYesYesYesYes
SECAT Performance Reports
Campus Clinic
Sep-05
ALL PATIENTS Diabetes Data: 9/1/04-9/1/05
ProviderHeimsKennedyMooreSteinmetzSwieskowskiGoal
Total Patients1006914591138
Process goals:
HgAlc last 12 mo.89%75%82%87%94%85%
LDL last 12 mo.73%57%60%73%89%85%
SBP last 12 mo.84%75%80%88%96%85%
Microalb last 12 mo.70%33%50%74%86%70%
Overall process goal %79%60%68%81%91%80%
Overall process goal met?NoNoNoYesYes
Outcome goals:
% HgAlc < 8.084%62%73%73%92%70%
% LDL < 13076%72%74%84%93%70%
% SBP < 14084%75%88%92%77%70%
Overall outcome goal %81%70%78%83%87%70%
Overall outcome goal met?YesYesYesYesYes
8-19-05
SECAT Performance Reports
Campus Clinic
Aug-05
WELLMARK Diabetes Data: 8/19/04-8/19/05
ProviderHeimsKennedyMooreSteinmetzSwieskowskiGoal
Total Patients1513273014
Process goals:
HgAlc last 12 mo.87%77%85%83%86%85%
LDL last 12 mo.67%77%63%77%86%85%
SBP last 12 mo.87%85%85%87%86%85%
Microalb last 12 mo.67%62%63%73%79%70%
Overall process goal %77.00%75.00%74%80%84.00%80%
Process goal met?NoNoNoYesYes
Outcome goals:
% HgAlc < 8.092%70%61%76%92%70%
% LDL < 13070%90%71%82%92%70%
% SBP < 14092%90%78%93%83%70%
Overall outcome goal %85%83%70%84%89%70%
Overall outcome goal met?YesYesYesYesYes
SECAT Performance Reports
Campus Clinic
Aug-05
Wellmark HTN Data: 8/19/04-8/19/05
ProviderHeimsKennedyMooreSteinmetzSwieskowskiGoal
Total Patients4868728142
Process goals:
SBP last 12 mo.98%93%90%95%100%85%
Lipids last 30 mo.94%84%83%88%95%85%
Glucose last 30 mo.88%71%75%90%98%85%
Microalb last 12 mo.85%49%65%74%88%70%
Overall process goal %91.00%74%78.00%87.00%95.00%80%
Process goal met?YesNoNoYesYes
Outcome goal:
% SBP < 14074%78%72%78%83%70%
Overall Outcome goal met?YesYesYesYesYes
8-05
SECAT Performance Reports
Campus Clinic
Aug-05
WELLMARK Diabetes Data: 8/1/04-8/1/05
ProviderHeimsKennedyMooreSteinmetzSwieskowskiGoal
Total Patients15 (14)13 (10)29 (24)30 (23)13 (11)
Process goals:
HgAlc last 12 mo.93% (80%)77% (80%)90% (88%)80% (83%)92% (82%)85%
LDL last 12 mo.67% (64%)77% (70%)59% (63%)70% (74%)92% (82%)85%
SBP last 12 mo.87% (79%)85% (80%)90% (88%)83% (78%)92% (82%)85%
Microalb last 12 mo.60% (64%)54% (60%)45% (54%)67% (70%)85% (73%)70%
Overall process goal %76.75%73.25%71%75%90.25%80%
Process goal met?NoNoNoNoYes
Outcome goals:
% HgAlc < 8.093% (83%)70% (76%)66% (67%)75% (68%)92% (88%)70%
% LDL < 13080% (77%)90% (85%)71% (67%)86% (83%)92% (100%)70%
% SBP < 140100% (100%)90% (88%)85% (81%)92% (94%)83% (89%)70%
Overall outcome goal %91%83%74%84%89%70%
Overall outcome goal met?YesYesYesYesYes
SECAT Performance Reports
Campus Clinic
Aug-05
Wellmark HTN Data: 8/1/04-8/1/05
ProviderHeimsKennedyMooreSteinmetzSwieskowskiGoal
Total Patients53 (51)70 (70)75 (81)81 (82)43 (41)
Process goals:
SBP last 12 mo.98% (96%)94% (87%)92% (91%)96% (95%)100% (100%)85%
Lipids last 30 mo.89% (84%)83% (75%)81% (75%)88% (85%)88% (96%)85%
Glucose last 30 mo.83% (80%)69% (61%)69% (62%)89% (78%)98% (95%)85%
Microalb last 12 mo.81% (67%)46% (24%)61% (30%)73% (67%)93% (91%)70%
Overall process goal %87.75%73%75.75%86.50%94.75%80%
Process goal met?YesNoNoYesYes
Outcome goal:
% SBP < 14074% (78%)73% (74%)73% (70%)75% (77%)83% (83%)70%
Overall Outcome goal met?YesYesYesYesYes
SECAT Performance Reports
Campus Clinic
Aug-05
ALL PATIENTS Diabetes Data: 8/1/04-8/1/05
ProviderHeimsKennedyMooreSteinmetzSwieskowskiGoal
Total Patients121 (116)71 (65)155 (143)98 (88)148 (148)
HgAlc last 12 mo.82% (80%)72% (69%)78% (78%)77% (76%)86% (84%)85%
% HgAlc < 8.083% (87%)65% (63%)73% (73%)74% (73%)93% (91%)70%
LDL last 12 mo.58% (57%)55% (48%)46% (46%)56% (58%)76% (72%)85%
% LDL < 13081% (83%)71% (68%)72% (71%)87% (87%)94% (95%)70%
SBP last 12 mo.72% (70%)69% (65%)77% (76%)77% (74%)85% (83%)85%
% SBP < 14085% (80%)78% (71%)84% (84%)88% (87%)74% (77%)70%
Microalb last 12 mo.55% (54%)25% (23%)34% (31%)52% (51%)68% (66%)70%
7-05
SECAT Performance Reports
Campus Clinic
Jul-05
WELLMARK Diabetes Data: July '04-July '05
ProviderHeimsKennedyMooreSteinmetzSwieskowskiGoal
Total Patients1410242311
HgAlc last 12 mo.86%80%88%83%82%85%
% HgAlc < 8.083%76%67%68%88%70%
LDL last 12 mo.64%70%63%74%82%85%
% LDL < 13077%85%67%83%100%70%
SBP last 12 mo.79%80%88%78%82%85%
% SBP < 140100%88%81%94%89%70%
Microalb last 12 mo.64%60%54%70%73%70%
ALL PATIENTS Diabetes Data: July '04-July '05
ProviderHeimsKennedyMooreSteinmetzSwieskowskiGoal
Total Patients116 (118)65 (67)143 (144)88 (93)148 (148)
HgAlc last 12 mo.80% (79%)69% (69%)78% (81%)76% (76%)84% (85%)85%
% HgAlc < 8.087% (85%)63% (62%)73% (70%)73% (70%)91% (91%)70%
LDL last 12 mo.57% (53%)48% (43%)46% (43%)58% (63%)72% (71%)85%
% LDL < 13083% (96%)68% (93%)71% (84%)87% (88%)95% (100%)70%
SBP last 12 mo.70% (68%)65% (64%)76% (78%)74% (76%)83% (84%85%
% SBP < 14080% (77%)71% (70%)84% (84%)87% (86%)77% (78%)70%
Microalb last 12 mo.54% (55%)23% (22%)31% (27%)51% (49%)66% (64%)70%
HTN Data: July '04-July '05
ProviderHeimsKennedyMooreSteinmetzSwieskowskiGoal
Total Patients51 (42)70 (44)81 (60)82 (51)41 (24)
SBP last 12 mo.96% (95%)87% (75%)91% (87%)95% (90%)100% (100%85%
% SBP < 14078% (76%)74% (54%)70% (65%)77% (81%)83% (80%)70%
Lipids last 30 mo.84% (81%)75% (64%)75% (65%)85% (80%)88% (96%)85%
Glucose last 30 mo.80% (79%)61% (48%)62% (48%)78% (72%)95 % (100%)85%
Microalb last 12 mo.67% (69%024% (20%)30% (28%)67% (61%)83% (92%)70%
4-05
3-05
SECAT Performance Reports
Campus Clinic
Diabetes Data: April '04-March '05
ProviderHeimsKennedyMooreSteinmetzSwieskowskiUdelhofenGoal
Total Patients89511157513515
A1c Rate97%94%97%93%96%100%85%
A1c %
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RRBP Diabetes Pilot DataN=497 Wellmark patients
Wellmark Blue Cross Blue Shield 2006
Chart1
0.78A1c %
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Cost of Poor Glycemic Control
Wellmark Blue Cross Blue Shield 2006
1% reduction in HgA1c saves $685 - $950 per year
JAMA. January 10, 2001
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Chronic Care Model Spread2002: Joined IHI IMPACT2 Clinics2004: Grant for disease registry3 Clinics2004: RRBP Pilot4 Clinics2005: RRBP second year13 Clinics
Wellmark Blue Cross Blue Shield 2006
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Program ExpansionIncrease number of physicians in program
StructureMust align with national standardsMonitor CMS, NQF other standards setting organizationsFocus on Diabetes, Asthma, prevention
Baseline performance of physicians
Support provider change processes
Reduce variation in program administration
Wellmark Blue Cross Blue Shield 2006
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Critical to SuccessWillingness to adopt change
Active involvement of the entire physician care team
Effective patient follow-up
Application of technology to processes
Ongoing evaluation of progress
Clear measures and measurements
Wellmark Blue Cross Blue Shield 2006
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How will Wellmark support change?Work with clinical community to identify barriers
Implement technology to encourage reduction of practice variation
Support relationship between patient and physician
Promote patient advocacy and education
Engage all stakeholders in the process
Encourage and support Quality
Recognize and reward as appropriate
Wellmark Blue Cross Blue Shield 2006
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How does technology help?Change Processes First
Technology supports changeMonitoring of patient care coordinationMore timely feedback on performanceAppropriate information sharing
Wellmark believes that technology is a key enabler
Wellmark Blue Cross Blue Shield 2006
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What kind of technology?Align cost with expected benefit
Incremental improvements vs. Big BangPlan for change Migrate over timeDo Not interrupt serviceAllow for successes to fuel innovation
Minimize re-work / duplicate entry
Integrate tools into office processes
Wellmark Blue Cross Blue Shield 2006
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Support adoption of changeIdentify your change champions
Listen to concerns
Set achievable goals
Work together to monitor progress
Celebrate small wins
Educate others on what is in it for them
Wellmark Blue Cross Blue Shield 2006
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Financial Incentives Future reward structure componentsQuality clinical suite measuresCost generic vs. brand prescription rates, ER visits, Inpatient days, etc.
Rewards will be based on Improvement in agreed upon Quality Measures
Wellmark Blue Cross Blue Shield 2006
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Wellmarks Next StepsEvaluate other opportunities for measurement
Work with clinicians to increase program scope
Begin working with specialists
Improve performance metrics and monitoring
Celebrate improved quality
Wellmark Blue Cross Blue Shield 2006
McGlynn Study, Midwest Business Group on Health StudyDouble-digit increases on already significant premiumsCompetitive disadvantage to businessesA family of four insurance topping 10k? Not sustainableImprove Adherence National Guidelines which is at 54% Electronic data collectionsProcess improvementConcept of coordination of care / Wagner Chronic care modelTalk about Medical Home conceptWellmark provided access to case managers, education meeting reimbursementCommunity focused approach Influential leaders, Quality / Cost buy in and tie-inConcept is to collaborate to drive change in our Health care systemExemption from prior authorization requirements for all drugs requiring a prior authorization under the pharmacy benefit
Key Success criteria:Strong physician leader advocating for changeTechnology to support case coordination for chronic patientsInvolvement of entire care team in improving qualityFeedback on performance as close to real-time as possibleRedesign health care delivery - Example (S-Codes), Medical HomePromote Physician relationship with Wellmark Include employer groups as active stakeholders