national behavioral consortium portland, oregon june 2007
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Rick Weisblatt, PhD Harvard Pilgrim Health Care. National Behavioral Consortium Portland, Oregon June 2007. Harvard Pilgrim Overview. Harvard Pilgrim Health Care. Not-for-profit health plan licensed to do business in New Hampshire, Massachusetts and Maine - PowerPoint PPT PresentationTRANSCRIPT
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National Behavioral Consortium
Portland, Oregon June 2007
Rick Weisblatt, PhD
Harvard Pilgrim Health Care
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Harvard Pilgrim Overview
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Harvard Pilgrim Health Care
Not-for-profit health plan licensed to do business in New Hampshire, Massachusetts and Maine Over 1million members as of January, 2007
Solid financial performance in a highly competitive marketplace
Expanded portfolio of self funded options with acquisition of Health Plans, Inc.
A year of national and local accolades – “Best Place to Work” in 2005 from Boston Business Journal
Top Leadership Team 2005 in healthcare by HealthLeaders Magazine
US News and World Report / NCQA : #1 Health Plan in America 3rd year running
Behavioral health partner – United Behavioral Health
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Harvard Pilgrim range of products
Comprehensive Product Portfolio: Harvard Pilgrim HMO
Harvard Pilgrim POS
Harvard Pilgrim PPO
Harvard Pilgrim HSA PPO Plans
HPHC Definity HRA Plans
Including the more affordable… Harvard Pilgrim Best Buy HMO Harvard Pilgrim Tiered-Copay HMO Harvard Pilgrim NetOption NH HMO Harvard Pilgrim Best Buy POS
Available on both Fully and Self-insured funding arrangements
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Market Context
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Utilization increases continue
Provider rate demands unabated
Technology advances at a dizzying clip
Not enough teeth in Evidence Based Medicine
Provider-level performance measures still primitive
Busy providers have little incentive to negotiate
Managed care “tools” eliminated or have run their course
Medicare and Medicaid continue to be “under-funded”
States look to health plans to fund budget shortfalls
Purchasers and consumers are cognitively dissonant
Utilization increases continue
Provider rate demands unabated
Technology advances at a dizzying clip
Not enough teeth in Evidence Based Medicine
Provider-level performance measures still primitive
Busy providers have little incentive to negotiate
Managed care “tools” eliminated or have run their course
Medicare and Medicaid continue to be “under-funded”
States look to health plans to fund budget shortfalls
Purchasers and consumers are cognitively dissonant
The marketplace is kind of a mess…
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Medical Trends Medical Trends
Aging population Patient demand Chronic illness – prevalence, longer life expectancy New technologies Pharmacy industrial complex Supply-driven market Fragmented care system Regulation
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Target high ROI areas
Maximally leverage the member
Multi-pronged approach
Align everyone’s incentives
Drive evidence-based practice
Bring clinical IT into the 21st century
Public disclosure of meaningful data
Health plan responseHealth plan response
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High
Low2002 2012
Value of Health
Benefits
Impact on Americans
Key Evolutionary Steps
Performancecomparisons
For hospitals, MDs & Tx
Market sensitivity to performance
ClinicalRe-engineering
By MDs,hospitals
Quality Costs
PerformanceDisclosure
Consumerism & Payfor Performance
Care SystemResponse
Source: Arnie Milstein
Value TransformationValue Transformation
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Behavioral Health in 2007
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Just some of the issues…
Patient protection and appeals rights
Coverage mandates and expansion
Parity
Cost shifting from states
Carve in vs. Carve out
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Managing Utilization: Wennberg & Fisher’s: Categories of Medical Care
Effective care and medical error
Preference-sensitive care
Supply sensitive care
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Supply-Sensitive Care – Capacity Determines use
Strongly correlated with resource supply
Examples include medical admissions, ICU stays, physician visits, specialty referrals, lab and radiology testing, especially in the last six months of life
Medical evidence weak or non-existent; patient preferences and values should play a significant role
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Supply-Sensitive Care : Highest vs Lowest Spending Regions
1.00 1.5 2.00.5 25 3.0
1.00 1.5 2.00.5 25 3.0
Office Visits
Initial Inpatient Specialist ConsultationsInpatient Visits
Psychotherapy Visits% of Patients seeing 10 or more MDs
Physician Visits
Electrocardiogram
Ambulatory ECG (Holter)Echocardiogram
Diagnostic Cardiology Procedures
Lower in High Spending Regions Higher in High Spending Regions
Chest X-ray
Ventilation Perfusion ScanCT / MRI Brain
Imaging Tests
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HEDIS National Performance Trends
Follow Up within 7 days
0.010.020.030.040.050.060.070.080.0
2002 2003 2004 2005 2006
% C
ases Mean
90th %ile
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HEDIS National Performance Trends
Follow Up within 30 days
65.0
70.0
75.0
80.0
85.0
90.0
2002 2003 2004 2005 2006
% C
ases Mean
90th %ile
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HEDIS National Performance Trends
AntiDepressant - Contact
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
2002 2003 2004 2005 2006
% C
ases Mean
90th %ile
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HEDIS National Performance Trends
AntiDepressant - Acute
0.010.020.030.040.050.060.070.080.0
2002 2003 2004 2005 2006
% C
ases Mean
90th %ile
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HEDIS National Performance Trends
AntiDepressant - Continuation
0.0
10.0
20.0
30.0
40.0
50.0
60.0
2002 2003 2004 2005 2006
% C
ases Mean
90th %ile
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Harvard Pilgrim
Pay for Performance and
Recognition Programs
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Impacting Provider Performance
Transparency and Disclosure
Public Reporting and Consensus Measures
Rewards and Recognition
Pay for Reporting
Pay for Performance
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Strategic Quality InitiativesCollaborate with key partners on QI initiatives
Rewards for Excellence: OUTCOMESReward practices for achieving desired outcomes
Shared Savings/EfficiencyShare savings based on efficient use of providers/services
Clinical Information TechnologyInvest in CIT to improve care processes, outcomes, and efficiency
Rewards for Excellence: PROCESSReward consistent performance in key care processes
Quality Grant ProgramImplement local QI programs, aligned with HPHC's QI Plan
Infrastructure FundingImplement basic practice management elements
Medical Director Stipendget an engaged clinical partner
Evolution of Practice Capabilities
Evolution of Quality Incentive Programs
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Overview of P4P
Encourage and reward investments and improvements in clinical outcomes and clinical infrastructure
Primary Messages: Recognizing Excellence and Rewarding Improvement
Recognition of need to clearly support medical group administration (Medical Director and Administrative Stipend)
Use of efficiency measures such as lab Steerage and Tier 1 prescribing
Introduction of outcomes based performance, focusing on clinical values for Diabetes HbA1c and LDL measures
Performance measures structured to align with various practice types and within various contract models
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Quality Advance Program
Introduced in 2004
Complemented HPHC’s shift away from risk based contracts – provided “upside bonus ” for high quality care
Portfolio of elements developed through the evolution of P4P
Practices can earn up to $4.25 pmpm in 2006
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Quality Advance Program 2006Med. Dir. Stipend Supports Medical Directory role, described in contract
Practice Admin Stipend Supports group’s infrastructure
Efficiency/Shared Svgs: Lab/Path
Promotes use of cost- effective lab providers
Efficiency/Shared Svgs: Tier 1 Rx %
Promotes Tier 1 drug prescribing
Clinical Information Technology (CIT)
Promotes adoption of systems to manage patient populations and improve safety- registries, EMR, CPOE – consistent with Institute of Medicine guidelines
Rewards for Excellence (R4E)
Rewards LCUs for excellent performance (national 90th percentile) on selected HEDIS measures. In 2006, bonus for Diabetes outcome values (HbA1c and LDL).
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Quality Grants Program
Unique to HPHC; valued by the physician and employer communities
Since 2000, 109 grants awarded for $8.6M Proposals aligned with IOM quality goals, on a topic of
strategic importance to HPHC HPHC Medical Leadership and Harvard Pilgrim
Physician Association Board review proposals Funding based on practice membership and project
scope ($25K-$125K)
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2006 Quality Grants Program
19 grants awarded to MA, NH, ME practices (out of 32 proposals)
Topics: Health IT (10), Reducing Disparities in Healthcare (5), Depression (3), ADHD (1)
Total funding: $1.3 million
Grant synopses posted on HPHC Provider site
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HPHC Honor RollPhysician Group Honor Roll- Adult & Pedi (since ‘03) An Adult practice must show performance above the national 90th
percentile in at least 9 of 11 HEDIS measures. A Pediatric practice must show performance above the national 90th
percentile in at least 4 of 5 HEDIS measures. Recognition on HPHC member site:
Practice name listed Icons in provider directory for PCPs in these practices
Hospital Quality Disclosure Designed to show excellence in CMS, JCAHO, and Leapfrog measures HPHC has adopted the N.H. Foundation for Healthy Communities data set
for reporting NH hospitals
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And CMS is getting into the game
From presentation by Regional CMS Administrator Dr. Charlotte Yeh on April 2,
2007
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CMS as a Public Health Agency
Vision: To achieve a transformed & modernized health care system Accurate & Predictable Payments
High Value Health Care
Confident Informed Consumers
Collaborative Partnerships
From presentation by Regional CMS Administrator Dr. Charlotte Yeh on April 2,
2007
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Physician QualityReporting Initiative (PQRI) Eligible Professionals
Practitioners described in Social Security Act (SSA) Section 1842(b)(18)(C)
• Physician Assistant• Nurse Practitioner• Clinical Nurse SpecialistClinical Nurse Specialist• Certified Registered Nurse Anesthetist • Certified Nurse-Midwife • Clinical Social WorkerClinical Social Worker• Clinical PsychologistClinical Psychologist• Registered Dietitian• Nutrition Professional
From presentation by Regional CMS Administrator Dr. Charlotte Yeh on April 2,
2007
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Physician QualityReporting Initiative (PQRI)
Quality Measures 74 “2007 PVRP” quality measures posted on December 5, 2006 adopted in
statute
Final list of 74 PQRI quality measures posted at www.cms.hhs.gov/PQRI, as a download on the Measures/Codes webpage
Antidepressant medication during acute phase for patients with new episode of major depression:
Acute phase defined as 12 weeks. 18 years and older.
Participating eligible professionals who successfully report may earn a 1.5% bonus, subject to cap
From presentation by Regional CMS Administrator Dr. Charlotte Yeh on April 2,
2007
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CMS looking at efficiency as well
Efficiency Is One of the Institute of Medicine's Key Dimensions of Quality
1. Safety
2. Effectiveness
3. Patient-Centeredness
4. Timeliness
5. Efficiency: absence of waste, overuse, misuse, and errors
6. Equity
• Institute of Medicine: Crossing the Quality Chasm:
A New Health System for the 21st Century, March, 2001.
From presentation by Regional CMS Administrator Dr. Charlotte Yeh on April 2,
2007
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CMS’ Cost of Care Measure Development
CMS’ Cost of Care Measurement Goals
To develop meaningful, actionable, and fair cost of care measures of actual to expected physician resource use
Evaluate episode grouper software as measurement tool
To link cost of care measures to quality of care measures for a comprehensive assessment of physician performance
From presentation by Regional CMS Administrator Dr. Charlotte Yeh on April 2,
2007
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Bringing pay for performance to the behavioral health
community
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Considerations for Behavioral Health P4P
Set the stage for accountability Promote consensus measures HEDIS and CMS Clinician reporting Public reporting Recognition programs Incentives: financial and administrative
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Issues
Self-reported specialties and credentialing
Lack of consensus outcomes measures
Groups practice vs. individual cottage industry
Privacy, patient protection and appeals
Parity
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Some measure possibilities
Generic prescribing
Poly-psychopharmacology
Visits/member/year; risk and diagnosis adjusted
Outcomes tools
HEDIS Behavioral Health
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Incentives
Honor Roll and Report Card
Self management
Steerage
Fee schedule inflator or flat dollars/unique member treated
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Incentive programs for B.H. providers UBH/PBH ALERT outcomes tool: steerage with pilot for financial incentive. Anthem: Coordination of care, CD treatment planning, patient satisfaction, HEDIS. Mass. Behavioral Health Partnership (Medicaid): Training in motivational interviewing for CD, inpatient LOS, use of outcomes tool (B.H. Labs). State of Delaware: CD measures including treatment continuation. Hawaii BCBS with major provider group: HEDIS measures, process measures.