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Government Programs: Lessons from the CMS Physician Group Practice (PGP) Demonstration Project- Emphasis on Heart Failure 3 3 rd rd National Pay for Performance Summit National Pay for Performance Summit February 28, 2008 February 28, 2008 F. Douglas Carr, MD, MMM Medical Director, Education & System Initiatives Billings Clinic

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Government Programs: Lessons from the CMS

Physician Group Practice (PGP) Demonstration Project-

Emphasis on Heart Failure

33rdrd

National Pay for Performance SummitNational Pay for Performance SummitFebruary 28, 2008February 28, 2008

F. Douglas Carr, MD, MMMMedical Director, Education & System Initiatives

Billings Clinic

Outline•

Intro Billings Clinic

PGP mechanics•

Focus on our approach to Heart Failure

Performance Year 1 Results•

Observations

Questions•

Barriers to Remote Monitoring

What is Billings Clinic?•

Group Practice–

w/ 225 Physicians, 65 midlevels, 29 (~50 sub-) specialties (Allergy to Urology)

10 clinic locations–

272 (220) bed tertiary hospital–

Manage/support 7 CAHs –

3000+ Committed Employees–

3rd

largest employer in Montana

Integrated Delivery System/ Medical Foundation–

Board of Directors: community-based–

Leadership Council (Internal Board): physician majority + senior

administrators

Service Region Locations

Riverton

Fremont

Casper

Powell

Park

Cody

Hot Springs

Thermopolis

Bighorn

LovellGreybull

WashakieWorland

SheridanSheridan

Johnson

Buffalo

Campbell

GilletteCrook

LincolnFlathead

Sanders

Mineral

Lake

Glacier

Missoula

Ravalli

Beaverhead

GraniteDeer

Lodge

Powell

Toole

Pondera

Teton

Lewis & Clark

Cascade

Jefferson

Silver Bow

Broa

dwat

er

Madison

Gallatin

Park

Sweet Grass

Stillwate

r

MeagherWheatland

Judith Basin

Chouteau

Libe

rty Hill

Blaine

Fergus

Golden Valley

CarbonBig Horn

Yellowstone

Musselshell

Petroleum

Phillips

Valley

Garfield

Rosebud

Treasure

Powder River

Carter

CusterFallon

PrairieWibaux

Dawson

McCone

Richland

Roosevelt

SheridanDaniels

Missoula

Butte

Dillon

Havre

Lewistown

Livingston

Columbus Billings

Red Lodge

Hardin

RoundupForsyth Miles City Baker

Glendive

Sidney

Wolf PointGlasgow

Weston

Natrona

Great Falls

Kalispell

I-15 I-90

I-25

Williams

Williston

Divide

McKenzie

Dickinson

Golden V

alleyB

illings

Dunn

Stark

Slope

BowmanAdams

Hettinger

I-94

HWY 2

Scobey

Big Timber Colstrip

Bozeman

Affiliate Management Services

Columbus -

Stillwater Hospital

Colstrip -

Colstrip Clinic

Forsyth -

Rosebud Healthcare

Lovell -

North Big Horn Hospital

Red Lodge -

Beartooth Hospital

Big Timber -

Pioneer Medical Center

Livingston -

Livingston Healthcare

Scobey -

Daniels Memorial Hospital

Clinic Locations & Number of Providers

Billings Clinic -

Cody (7 MDs, 1 PA)

Bozeman OB/Gyn (6 MDs, 2 NPs, 1 PA)

Billings Clinic -

Forsyth (1 PA)

Billings Clinic-

Main (200 MD, 47 PA)

Billings Clinic -

West (8 MDs, 1 PA)

Billings Clinic -

Miles City (10 MDs, 3 PAs)

Billings Clinic -

Red Lodge (4 MDs)

Billings Clinic -

Columbus (2 MDs, 1 NP)

Billings Clinic -

Heights (4 MDs, 1 PA)

Counties with Affiliate or Branch Clinic

Other Service Area CountiesDecember 2007

Montana: 147,138 square miles and 922,002 people

CMS PGP Objectives

Health Care Education and Research

Encourage coordination of Part A & Part B•

Coordinate care for chronically ill and high cost beneficiaries in an efficient manner

Decrease the growth in Medicare spending over the next 3 years

Everett, WA –

Everett Clinic

Marshfield, WI –

Marshfield Clinic

Springfield, MO –

St Johns

Danville, PA-Geisinger

Billings, MT-Billings Clinic

St. Louis Park, MN –

Park NicolletWinston-Salem, NC-Novant- Forsyth

Physician Group Practices

Integrated Delivery Systems

Academic & Network Org.Middletown, CT –

Integrated Resources for Middlesex Area (IRMA)

Ann Arbor, MI -

University of Michigan

Bedford, NH-Dartmouth Hitchcock

10 Organizations

CMS PGP Project Timeline

Base Year:

Calendar year 2004

Performance Year 1:

April 1, 2005 -

March 31, 2006

Performance Year 2:

April 1, 2006 -

March 31, 2007

Performance Year 3:

April 1, 2007 -

March 31, 2008

Performance Year 4: April 1, 2008 –

March 31, 2009

PGP Demo Concepts

• Medicare Fee For Service continues as before• If PGP is able to reduce the growth of Medicare

spending for the cohort under its care compared to a regional comparison, CMS will share part of its savings with PGP

• Budget neutral project for CMS

• Meeting Financial Target= “Gate”

• Once “Open”, PGP’s portion dependent on meeting Quality Measures

CMS PGP Beneficiary Assignment

• To be assigned to PGP:– PGP must provide to beneficiary

• at least one E&M office or other OP service• plurality of E&M office/OP services provided in the year

• To be assigned to Comparison Group– Beneficiary must have at least one E&M Service– Cannot have had any E&M services at PGP during the

current year or been assigned to the PGP previously.– Must reside in a service area county.– Service area counties must provide 1% of eligible

beneficiaries.

PY-1 Billings Clinic versus Comparison Group Service Area Distribution

Riverton

Fremont

Casper

Park

10 V 12 %

Hot Springs

Thermopolis

Bighorn3 V 4 %

WashakieWorland

Sheridan1 V 16 %

Johnson

Buffalo

Campbell

GilletteCrook

LincolnFlathead

Sanders

Mineral

Lake

Glacier

Missoula

Ravalli

Beaverhead

Granite

Deer Lodge

Powell

Toole

Pondera

Teton

Lewis & Clark Cascade

Jefferson

Silver Bow

Broa

dwat

er

Madison

Gallatin

Park

Sweet Grass

Stillwate

r

MeagherWheatland

Judith Basin

Chouteau

Libe

rty Hill

Blaine

Fergus

Golden Valley

CarbonBig Horn

Yellowstone

Musselshell

Petroleum

Phillips

Valley

Garfield

Rosebud

Treasure

Powder River

Carter

CusterFallon

Prairie Wibaux

Dawson

McCone

Richland

Roosevelt

SheridanDaniels

Missoula

Anaconda

Butte

Dillon

Bozeman

Havre

Lewistown

1 v 7 %4 v 2 %

61v 40 %

5 v 3 %

Hardin

2 v 1 % 2 V 3 %

8 v 4 %Baker

1 v 5 %

Sidney

CulbertsonWolf Point

2 v 3 %

16.4% of Assigned Beneficiaries in PY-1 are outside of the PGP Service area

CMS PGP Demonstration Project

Bonus Sharing Methodology

PGP Financial Target Calculation:1. Identify comparison group in same counties2. Calculate rate of growth of per capita

expenditures from base to performance year3. Comparison group growth rate is applied to the

PGP’s base year4. Individual risk adjustments (HCC) apply to both

groups to account for case mix changes between years

CMS PGP Demonstration Project

Bonus Sharing Methodology• Medicare Savings =

(Per Capita Target – PGP’s Performance Year Per Capita Expenditure) X (Assigned Beneficiaries)

• Bonus Sharing Formula– 20% retained in Medicare Trust Fund– 80 % eligible to PGP

• Percentage based on both financial and quality indicators and changes each performance year

PGP Project Financial Model

SVNGS >2%

20% 20% ⇒⇒ CMSCMS

80% 80% Performance PayPerformance Pay

0.3 Q

0.7 E

0.4 Q

0.6 E

0.5 Q

0.5E

Y1 Y2 Y3 Y4

Q: QualityE: Efficiency

0.5

Q

0.5 E

CMS PGP Quality Measures

Year 1:

Diabetes•

Year 2:

Year 1 plus HF

and CAD

Year 3:

Year 2 plus Hypertension and colorectal and breast

cancer

screenings

+ flu and pneumonia vaccines

Total 32

OutpatientOutpatient

Quality Measures: Diabetes % of patients in performance year with

Claims Based•

Hgb-A1c tests

LDL test•

Microalbumin testing or Dx/Tx for nephropathy

Retinal exam by MD/OD:1year/high risk,2 years/low risk

Chart/Hybrid Based•

HgbA1c ≤

9.0%

BP< 140/90•

LDL<130

Complete foot exam documented

Influenza vaccine•

Pneumoccocal vaccine

Quality Measures: HF % of patients in performance year with

Claims Based•

LV-EF in same year if hospitalized for HF

Chart/Hybrid Based•

Qualitative/quantitative LVF Assessment

Visits Weight documented•

Visits BP documented•

HF Education documented in last 6 months

LVSD on ß-blocker•

LVSD on ACEI•

HF/AF on Warfarin•

Influenza vaccine•

Pneumococcal vaccine

Quality Measures: CAD % of patients in performance year with

Claims Based•

Lipid profile

Chart/Hybrid Based•

LDL<130

Antiplatelet Rx•

Lipid Rx

Hx MI, on ß-blockers•

BP @ last visit

DM &/or LVSD on ACEI

Quality Measures: Preventive Care % of patients in performance year with

Claims Based•

50-69 y.o. w/

mammogram in current or prior year

Chart/Hybrid Based•

“Screened”

for colon

Cancer•

BP documented

Last BP<140/90 •

If BP is >140/>90 documented plan of care

PGP Quality Thresholds: Absolute

or Relative

Targets

The higher of 75% compliance, or the Medicare mean, or …

70th

percentile of Medicare HEDIS

10 % reduction in gap between administrative baseline and 100% compliance, or…

Base Year Data: Where does the $ go?

Components of Medicare Expenditures For Billings Clinic• Inpatient 40%• Hospital OP 24%• Part B 22%• SNF 7%• Home Health 3%• DME 4%

CMS PGP Mantra

Quality Measures

are OUTPATIENT driven.

Financial Savings

are INPATIENT

driven.

Base Year Data: What Diagnoses?

HCC 80: CHF 1,945 discharges•

HCC 92: Heart Arrhythmias 1,898

HCC 15-19: Diabetes 1,683 •

HCC 108: COPD 1,887

HCC 79: Card-Resp Failure 1,305•

HCC 105: Vascular Disease 969

HCC 131: Renal Failure 743

CMS PGP Patient Focus AreasCMS PGP Patient Focus Areas

METABOLIC DISEASE:

DIABETES

HTNCARDIOLOGY:

HF

CAD

Needless Admissions:5 Wishes

Nursing HomePsychiatryMedication

Reconciliation

PREVENTIVE CARE:

Colorectal & Breast Cancer Screening

Immunizations

EMR: Vehicle for Process Improvement

Chronic Disease Management–

Disease Registry–

Disease Management Modules (DM, HF, CAD, HTN)–

Clinical Guidelines–

Reports for organization and providers–

Patient information

Health Maintenance–

Cancer, Osteoporosis, etc. Screening–

Immunizations•

Patient Safety–

Medication reconciliation during transitions of care

Health Care Education and Research

Heart Failure•

Cost SavingsGoal: Decrease ‘All Cause’

Admissions 10-20% 50%–

Existing HF Clinic: 200 750 patients–

Technology leverage

Quality Improvements–

HF Clinic Re-design: Expand RNs, daily IP/OP coverage, Mid-level

Adopt new Treatment Guidelines–

HF Management POC Modules in Cerner–

Feedback to providers with patient report cards

HF Registry build > 3,000–

Effective Patient Education

Health Care Education and Research

CMS Quality Measures:

□□

Ejection Fraction Test

□□

Blood Pressure Screen

□□

Patient Education

□□

ACE/ARB Therapy

□□

Beta Blocker Therapy

□□

Smoking Status

Heart Failure Disease Module:

Alerts for Providers

E-form for Heart Failure Registry and Tel-

Assurance Program Enrollment

E-form for documenting Smoking Status and Education

E-form for documenting Heart Failure Education

Heart Failure Point-of-Care Summary Screen

1997 –

2005

: HF Program Prior to PGP

Outpatient tele-management program (POTs), within cardiac rehab–

HF inpatient pathway provider referral

Physician-directed Nurse management–

2.6 FTEs (RNs); M-F 0800-1700

150+ patients: discharged at 1 year if stable–

Reduced HF hospitalizations by about 10-20%?

PGP/CMS-RTI stats 2004: 1800 HF patients, 1900 admissions

How to have a greater impact?

Interactive Telephone System with Web-enabled Data Tracking

Developed @ Evanston Northwestern Hospital by Randy Williams, MD in late 1990’s

Utilizes daily

monitoring system for patients via Interactive Voice data collection

Validated, proven system that manages by exception

Allows for 1 RN to follow 2-300 patients•

Has demonstrated reduction of all-cause hospitalization >50% @ some hospitals

Interactive Telephone System with Web-enabled Data Tracking

Patients call daily between 4 AM and Noon

Data appears immediately on a web server

HF “Care Coaches”

(RNs) call outliers

Manage per HF protocols (diuretic ∆)

Refer to HF Clinic MD/NPP or PCP

Goal: coordinate care w/“Tx Physician”

Recorded Questions

1.

Have you noticed more swelling in the last day?

2.

Did you wake up short of breath last night?

3.

Did you sleep in a chair or prop up with pillows more than usual last night?

4.

Have you had any lightheadedness or dizziness in the last day?

5.

Please enter this morning’s weight. Have you felt more sort of breath in the last day?

The Challenges of Patient Adherence

17%Other

19%Failure to Seek Care

16%Inappropriate Rx

Rx Noncompliance24%

Diet Noncompliance24%

Vinson J Am Geriatr Soc 1990;38:1290-5

Disease Severity / Future Financial Risk

# of

At R

isk

Indi

vidu

als

Care MgmtTargets

Existing Approach to Chronic Population Care Management

Top 5-10% of population

Unmet Need and Unmanaged Risk

Pharos Target Population

Disease Severity / Future Financial Risk

# of

At R

isk

Indi

vidu

als

Telephonic Enhanced Adherence Monitoring

The Target Population

Current model of HF Program•

6 RNs providing 7day/week coverage

for IP education/enrollment and OP care management.

IP Care:–

Focused on ADHF patients (Case ID: referral, registry, admit Dx,

BNP, etc.)

Core Measures documentation assisted by new Cerner Powerforms–

Discharge planning: Euvolemia & Early follow-up visit (5 days)–

Opportunity for enrollment for other patients with HF

OP care:–

RN triage and intervention (pre-approved protocols for diuretics/electrolyte management)

~500 patients w/ HF use TelAssurance©•

Daily telephone call in, IVR system•

5 questions + weight variances precipitates RN follow-up–

Minimum # (~50) called at least monthly, unable to use TA

Midlevel :

Available for post-hospital, emergent, and Rx Titration per physician discretion

Billings Clinic Service Area

Riverton

Fremont

Casper

Powell

Park

Cody

Hot Springs

Thermopolis

Bighorn

LovellGreybull

WashakieWorland

SheridanSheridan

Johnson

Buffalo

Campbell

GilletteCrook

LincolnFlathead

Sanders

Mineral

Lake

Glacier

Missoula

Ravalli

Beaverhead

Granite

Deer Lodge

Powell

Toole

Pondera

Teton

Lewis & Clark Cascade

Jefferson

Silver Bow

Broa

dwat

er

Madison

Gallatin

Park

Sweet Grass

Stillwate

r

MeagherWheatland

Judith Basin

Chouteau

Libe

rty Hill

Blaine

Fergus

Golden Valley

CarbonBig Horn

Yellowstone

Musselshell

Petroleum

Phillips

Valley

Garfield

Rosebud

Treasure

Powder River

Carter

CusterFallon

Prairie Wibaux

Dawson

McCone

Richland

Roosevelt

SheridanDaniels

Missoula

Anaconda

Butte

Dillon

Bozeman

Havre

Lewistown

Livingston

Big Timber Columbus Billings

Red Lodge

Hardin

Roundup

Forsyth Miles CityBaker

Glendive

Sidney

CulbertsonWolf PointGlasgow

Primary

Secondary

Tertiary

Population Sq. MilesYellowstone 136,029 2,635Secondary 54,006 26,101Tertiary 341,927 92,630TOTAL: 531,962 121,366

Source: Claritas, Inc. 2005 Population Estimate

US Census Bureau Land Area Sizes

All Cause Hospitalizations in HF Patients

-

Per 1000 (using hospital and clinic for determining HF Population (HCC 80))

Residents of Yellowstone and Contiguous Counties only

400

500

600

700

800

900

1000

1100

Mar-04

Jun-04

Sep-04Dec-0

4Mar-0

5Ju

n-05Sep-05Dec-0

5Mar-0

6Ju

n-06Sep-06Dec-0

6Mar-0

7Ju

n-07Sep-07Dec-0

7

CombinedInterventionNon-intervention

Heart Failure Primary Dx Hospitalizations –

Per 1000 (using hospital and clinic data for determining

HF Population (HCC 80))

-

50.0

100.0

150.0

200.0

250.0

300.0

350.0

400.0

Mar-04

Jun-04Sep-04Dec-0

4Mar-0

5Jun-05Sep-05Dec-0

5Mar-0

6Jun-06Sep-06Dec-0

6Mar-0

7Jun-07Sep-07Dec-0

7

CombinedInterventionNon-intervention

Averted Admissions - All Payers

0.0020.0040.0060.0080.00

100.00

Jan-M

arch 06

April-J

une 06

July-

Sept 0

6Oct-

Dec 06

Jan-M

arch 07

April-J

une 07

July-

Sept 0

7Oct-

Dec 07

Quarters

Ave

rted

Adm

issi

ons

Averted Admissionsvs RTI Rate^̂

Averted Admissionsvs NonInterventionGroup^̂

>50% reduction in hospitalizationsor

~ 6/100/month enrolled in TA

Total: # 516 Medicare: ~80%

Averted Admissions - Medicare Program Savings

$-$100,000.00$200,000.00$300,000.00$400,000.00$500,000.00

Jan-M

arch 06

April-J

une 06

July-

Sept 0

6Oct-

Dec 06

Jan-M

arch 07

April-J

une 07

July-

Sept 0

7Oct-

Dec 07

Quarters

Med

icar

e Pr

ogra

m

Savi

ngs

Estimated programSavings vs RTI Rate

Estimated programSavings vsNonInterventionGroup

Estimated Cost Savings to MedicareUpper Est.: $2,770,000Lower Est.: $1,736,000

PGP PY-1 Results•

Press Release by CMS July 2007 (Q2PY3!)

result is improved Diabetes quality measures

across all org, most are > national

benchmarks•

Process Improvements were applied to all

patients/payers; no restriction of services•

Aggregate Savings

to CMS of ~$21M

over ~225,000 beneficiaries•

2/10 orgs (Marshfield Clinic & U Michigan) achieved >2% $7+M in bonus payments

Billings Clinic PY-1 Results•

Achieved 8/10 Diabetes targets, 20/22 total points (91%)

Did not exceed the 2% threshold, thus no bonus received in 1st

year

Inpatient costs reduced } vs. Comparison•

Outpatient costs higher } “

(HF and many other programmatic efforts not functional until PY-2)

Challenges•

Our Issues–

Cultural change management –

EMR enhancements: Not off-the-shelf (“certification”); Registry build–

PC Model: Access, Documentation, Process Redesign–

Medication Reconciliation –

Care Management –

Robust Advance Directives implementation

CMS/Methodology–

Investment in resources/infrastructure (cash flow, risk)–

Financial bar high, demo too short ( 5 years?)–

Data abstraction requirements–

Lack of real-time data from CMS–

Attribution of beneficiaries–

Comparison group selection –

Risk Adjustment (HCC): coding specificity,

Working with CMS

What have we learned from playing with CMS?

Delay in receiving data fails to support the improvement process

Initial results reflect the delay between process improvements and clinical outcomes.

Quality improvement may also not inherently be more efficient, especially in the short-term.

Coding specificity will play a significant role in national programs that attempt to track quality with claims data (e.g.. PQRI)

Observations on HCC risk adjustment scores

Base Year Variation among the 10 PGP groups: 0.821 to 1.308

PY-1 results were significantly influenced by the Δ between attributed and comparison groups

HCC scores tend to increase “2%/year in managed care markets”; demo range: 0.5% to 6.5%

Future of CMS Value Based Purchasing initiatives (P4P) likely to hinge on greater specificity of charge data–

Future Medical Home management fee likely will be risk adjusted–

MS-DRG and HCC risk drivers are similar: specificity & comprehensive, emphasis on some “usual suspects”

Statistical Challenges for Rural Counties?

Risk Adjustments for rural counties, especially with beneficiary numbers <1,000, can be very volatile. (>17%)

The net financial effects for Billings Clinic are greatly related to the change in Risk Adjustment. (-3% relative to comp group)

Observations

Look more broadly at interventions–

HF as 1°

Dx is 13% of all admissions for HF patients

PGP lessons may be hidden in the details–

2/10 achieved financial targets in 1st year

Success in individual programs may be lost in the overall analysis

After PY1, all groups are more aware that HCC risk adjustment is a CSF

Premier analysis of HF is limited to a more narrow hospital/episode of care perspective

Observations

DM by providers, not intermediaries, allows for direct intervention and best integration of care and QI into the care delivery system

Medical Home: Is the infrastructure sufficient to achieve the outcomes?

Not all diseases have same monetary impact or ROI/timeline–

HF vs. Diabetes, COPD, CAD, HTN, Cancer Prevention

The “Tyranny of FFS”

…….Any Questions?

Barriers to wide-spread adoption of remote monitoring to chronic care

Payment systems–

FFS promotes piece-work, lack of accountability of outcomes

No FFS recognition of DM or care coordination activities

3rd

Party vs. Provider-based DM

Providers can better integrate DM into clinical treatment

Coordination of IP/OP –

Greater clinical accountability for the total care of patient

EHR interface/ communication with all providers

Barriers to wide-spread adoption of remote monitoring to chronic care

Provider integration–

Coordination among specialties

Outpatient + Inpatient–

EHR is the vehicle for coordination and guideline use at POC

Dissemination of guidelines•

POC alerting/ordering/documentation –

Other infrastructure (human resources) required for DM

Registry build and maintenance–

Organizational change management

Barriers to wide-spread adoption of remote monitoring to chronic care

Provider Acceptance–

Professional change management (Team Process)

Workflow change–

Accountability/feedback (report cards)

Patient Acceptance–

Passive “Activated” (Wagner Chronic Care Model)

“Selling”

is not skill set in Health Care–

Enrollment is always less than reported

3rd

party: 10%•

Provider: 20%•

“Seller”: 30+%

Barriers to wide-spread adoption of remote monitoring to chronic care

HIT–

Interface/interoperability

Registry build and maintenance–

Current EHR “certification”

doesn’t include supporting

accepted quality measures–

Quality measures are not uniform

Reporting capabilities lagging•

Geographic–

Ideal for the model/technology

Increases provider interaction complexity