Baseline Demographic Variables

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Partnering for Value
David Share, MD, MPH Senior Associate Medical
Director, Health Care Quality Blue Cross Blue
Shield of Michigan
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BCBSMs Value PartnershipsProvider-Plan
Collaboration to improve outcomes and efficiency

• Current state
• Fragmented acute care focused patients are
  passive recipients of care consistently poor
  value
• Future state
• Integrated system designed to assure proactive
  management of population wellbeing care
  customized to individuals needs patients are
  active participants in care consistently high
  value
• Collaborating with physicians to modernize health
  care
• Forge a common vision of a preferred health
  system
• Energize physicians to lead change
• Charge them to transform system in which they
  practice
• Design an incentive program to achieve the vision

3
Now Future

• More
• Incremental change
• Reactive
• Defend status quo
• My patients/my practice
• Compete on quality

• Better
• Transformative
• Systematic
• Advocate for change
• Our community of patients
• Collaborate on quality

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Now Future

• Fragmented
• Acute care focus
• Problem oriented
• Reactive
• My records
• Hard copy
• dispersed

• Integrated
• Chronic care focus
• Goal directed
• Proactive
• Patients information
• Electronic
• accessible

5
Now Future

• Error prone
• Spotty
• Trees
• Led
• Caregiver

• Error free
• Consistent
• Forest
• Lead
• Caregiver

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Strategies for Improving Outcomes

• Steerage Direct patients to high-performing
  narrow networks/COEs
• Not effective on a population basis
• P4P reward high performance
• Addresses a narrow range of health care services
  due to limited ability to define and measure
  optimal care not subspecialty specific rewards
  past performance, doesnt catalyze fundamental
  change playing to the quiz focus on what is
  measurable, not necessarily what is important
• Partnering for Value
• Physician Group Incentives Multi-hospital,
  registry-based Collaborative Quality Initiatives
• Emphasizes collaborative and continuous quality
  improvement and transforming systems of care

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Partnering for Value overarching goals

• Optimize wellbeing, maximize health care
  efficiency
• Energize patients as partners in goal setting and
  self-management
• Raise the bar of quality community-wide, dont
  just reward high performers
• Transform systems of care assure proactive
  management of populations with chronic care needs

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Partnering for Value underlying assumptions

• System transformation is more likely if
• physicians interests are aligned with payers
  and purchasers interests
• physician groups own the responsibility
• groups have structure and active leadership (at
  the group and clinic levels)

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Partnering for Value underlying assumptions

• Physicians practice in groups (actual or virtual)
• Solo practice is unusual
• Even solo practitioners dont practice in
  isolation
• Cross coverage is standard, even for soloists
• PCPs rely on specialists, hospitalists, the ER
• Specialists sub-specialize

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Partnering for Value underlying assumptions

• Advantages of measuring group performance
• Supports and stimulates system transformation
• Less likely to reward past performance
• The needle moves slowly when measuring individual
  physician performance
• More valid than individual level measurement (low
  n, patient clustering, patient attribution)
• Physicians creative energies are focused on
  improving systems not defending personal practice

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Partnering for Value underlying assumptions

• Cross-group/institution collaboration yields more
  than competition on quality
• Improvement catalyzed by sharing best practices
• More variation exists in practices across groups
  than within groups
• Permits more robust analyses of link between
  processes and outcomes of care

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Optimizing Value in Physicians Practices

• Health plan can catalyze system transformation
• encourage formation of physician groups
• then high-functioning, integrated systems of care
• Resources are needed for physician groups to
  achieve optimal systems
• One size doesnt fit all Physician groups are in
  different stages of evolution ranging from
  vertically integrated, highly functioning systems
  to cottage industries

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BCBSMs Physician Group Incentive Program

• 16 groups 2,700 doctors 471,000 members
• Rewards system transformation
• One size doesnt fit all
• Goal is uniform high quality and cost effective
  care, with proactive management of populations of
  patients with chronic illness
• Focus is on implementing the Chronic Care Model
  Asthma, DM, CAD, HF, Depression as a
  co-morbidity linking specialists and PCPs

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Chronic Care Model

• Organization of the Delivery System
• Community Linkages
• Self-Management Support
• Decision Support (for clinicians)
• Delivery System Design (e.g., planned visits,
  shared visits, proactive, goal-directed outreach)
• Clinical Information Systems
• Integration of Chronic Care Model Components
  across settings of care

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Chronic Care Model
Health System
Community
Health Care Organization
Resources and Policies
ClinicalInformationSystems
DeliverySystem Design
Self-Management Support
Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Improved Outcomes
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PGIP Chronic Illness Workgroup Cross-group
collaboration

• Self-management
• Planned care visits
• System integration
• Process improvement
• Performance measurement

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Chronic Diseases Measures Gauge Impact and Guide
Transformation
PGIP Evidence Based Care Measures 2005 (Claims
Based)

• CHF Measures
• LDL Screening
• Beta Blocker Prescription Last 12 months
• ACE/ARB Use
• CAD Measures
• LDL Screening
• Beta Blocker Use after AMI
• Lipid Drug Use
• Statin Drug Use

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Chronic Diseases Measures Gauge Impact and Guide
Transformation
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Physician Organization Gain-sharing Program

• Physician Organization Gain-sharing Program
• 15 additional groups total of 4,500 doctors
  900,000 members (combined PGIP/POGS)
• Provider organizations take responsibility for
  acting on opportunities to improve efficiency
• Share realized net savings in pharmacy, lab,
  imaging and referrals (in-network) with PGIP and
  POGS groups
• Specialty gain-sharing
• cardiology improved efficiency in diagnostic
  service and pharmacy use EMR based-ambulatory
  discharge contract
• Oncology improved efficiency in diagnostic
  imaging and pharmacy use (epoetics anti-emetics
  emerging bio-tech drugs)

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2005 PGIP Accomplishments

• 8.9 million in incentive payments
• Physician groups are making significant
  investments in quality
• Physicians achieved 7 million in reduced
  prescription drug costs through the use of
  generic alternatives

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Physician Group Highlights

• PROMOTING INFORMATION INFRASTRUCTURE FOR
  IMPROVED PATIENT CARE
• Committed over 3 million to implement electronic
  medical office to facilitate ability to identify
  specific patient populations and compliance with
  evidence-based medicine and guidelines
• Planned electronic medical record implementation,
  including e-lab access and e-patient reminders
• Electronic health record initiative includes
  incentives for early adoption of technology
• Chose Chronic Disease Electronic Management
  System (CDEMS) for registries
• MAKING DISEASE REGISTRY INFORMATION AVAILABLE AT
  POINT OF CARE
• Populated registries for all four targeted
  conditions
• Provided financial incentive for doctors to
  review the documents listing diabetics in their
  panel to assure accuracy of lists
• Increased extent to which information is used and
  available electronically
• Incorporated reminder system for identified gaps
  in care, to be used directly with patients at
  point of service, with CDEMS
• incorporated lab data into registry

• DECISION SUPPORT
• Provided physicians with quarterly feedback on
  diabetes patients as well as group average, which
  allows identification of opportunities for
  improvement
• SELF-MANAGEMENT SUPPORT
• Successes reported associated with care of
  patients with diabetes in a Shared Medical
  Appointment mode
• Implemented health coaching
• ELECTRONIC INFORMATION ACCESS AND USE
• Provided online asthma action plan
• Piloted RelayHealth web visits, as a means of
  communicating with patients faxing prescriptions
  and managing scheduling
• IMPROVING PRESCRIBING PATTERNS
• Used incentive dollars to reward physicians who
  personally were responsible for over 50 generic
  dispensing rate
• Implemented E-prescribing for some primary care
  physicians in advance of full EMO capability
• Implemented e-prescribing at 35 sites with 113
  doctors
• Tried out use of an electronic generic sample
  card (30 day supply) and may expand the approach
• Introduced point of service generic dispensing

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Collaborative Quality Initiativesunderlying
assumptions

• Valid, evidence-based, nationally accepted
  performance measures cover a narrow slice of
  health care
• While valuable, conventional quality measurement
  isnt a panacea

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Collaborative Quality Initiativesunderlying
assumptions

• Simple performance measures dont address areas
  of care which are highly technical,
  rapidly-evolving and associated with scientific
  uncertainty
• Best addressed through collaborative,
  inter-institutional, clinical data registries,
  with coordinated QI programs

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Partnering for Value Collaborative Quality
Initiatives

• Essential elements of CQI Programs
• Complete, accurate, risk adjusted, confidential,
  provider-owned data
• Consortium as context for identifying and
  disseminating best practices
• Coordinating Center to assure rigor and guide
  cross-institutional study of practice patterns
  and their relation to outcomes
• Health plan support of consortium activity
• Aggregate provider accountability for assuring
  health care value

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Role of BCBSM

• Use leverage to convene competitive hospitals
• Provide neutral ground for collaboration
• Provide resources for data gathering and analysis
• Use Centers of Excellence program as catalyst for
  CQI

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Blue Cross Blue Shield of Michigan Cardiovascular
ConsortiumCollaborative Quality Improvement
Initiative In Coronary Angioplasty Mauro
Moscucci, MD, University of Michigan Project Lead
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BMC2 OBJECTIVES

• Generate knowledge linking processes and outcomes
  of care to help define optimal care
• Improve outcomes of PCI by collaboratively
  applying new knowledge in rapid-cycle, continuous
  quality improvement efforts
• Engage clinical and administrative leaders as
  quality improvement champions

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Areas of QI Focus

• Systematize care based on established guidelines
• e.g., aspirin, beta blockers, statins
• Scientific examination of unanswered questions
  about links between processes and outcomes of
  care
• e.g., pre-procedure statins lower renal failure
  and mortality risk identification of risk
  factors and preventive measures for kidney
  failure requiring dialysis

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Accomplishments to Date

• Evidence based learning linking processes and
  outcomes of care
• Disseminated in peer-reviewed literature
• Development of care management algorithms
• CQI interventions demonstrable improvement in
  selected processes and outcomes of care
• Using RCTs across hospitals to learn what works

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Accomplishments to Date

• Reduced heart attacks by 19
• Reduced unplanned coronary artery bypass surgery
  by 22
• Reduced kidney failure requiring dialysis by 57
• Reduced hospital deaths by 27
• Saved an estimated 8 million annually

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BMC2 Lessons Learned

• Blue leverage was key to convening competing
  providers and catalyzing effective, collaborative
  CQI
• Given procedure-specific information, and
  incentives, competing providers can collaborate
  and rapidly improve the quality of care
• Incentives to rigorously evaluate and re-engineer
  care accomplish more than focusing on selected
  performance metrics

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Expansion of BMC2 Model

• Cardiac Surgery (Michigan STCvS)
• Bariatric Surgery
• General and vascular surgery (NSQIP/ACS)
• Breast Cancer (NCCN)
• Hospital infection control MHA Keystone
• Cardiac Imaging
• Peripheral Vascular Intervention

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Expansion of BMC2 Model
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Hospital Incentive Program

• Pre-qualifying conditions focus on culture of
  safety and patient safety practices (ISMP NQF)
• 45 - 55 Quality and Patient Satisfaction
• 35 Efficiency (e.g., cost per case regional
  comparison generic drug use)
• 10 - 20 Collaborative Quality Initiatives

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Partnering for Value Assuring Appropriateness
In Cardiac Imaging

• Limit payment to providers participating in
  collaborative QI effort pertaining to new imaging
  services
• Implement clinical registry for cases in which
  such imaging is used
• Populate registry with data regarding the
  clinical context of such imaging (clinical
  scenario other testing and results)
• Incorporate clinical testing algorithms for
  common clinical scenarios into the registry
• Emphasize clinical management focus not
  modality-specific appropriateness criteria

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Partnering for Value Assuring Appropriateness
In Cardiac Imaging

• Examine patterns of use, and variation in such
  use, as they pertain to appropriateness criteria
  and efficiency concerns
• Measurement focus is on physician groups
  (physicians practice in groups, whether formally
  or informally)

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Partnering for Value Assuring Appropriateness
In Cardiac Imaging

• Parameters to study with regard to efficiency
• Imaging services per episode of care (for
  diagnosis post-event for chronic illness
  management)
• of negative imaging studies
• of use of multiple imaging modalities per
  patient in diagnosis and in care management
• with new imaging study PLUS invasive
  imaging/PCI
• services without known disease or active
  symptoms

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Summary

• Value Partnerships
• Based on a distinctively collaborative BCBSM
  philosophy
• Includes process, outcome, information
  technology, and cost measures
• Eight separate initiatives target physicians,
  physician groups and hospitals
• In 2005, paid out about 53.9 million in
  incentives
• PGIP 8.9 million
• Hospital P4P Program over 45 million
• Programs impact over two million members
• Improvements achieved in quality, cost and
  efficiency