Central%20Florida%20Health%20Care%20Coalition

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Central Florida Health Care Coalition
Celebrating 19 Years of Quality 1984-2003
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Central Florida Health Care Coalition
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Beliefs

• Quality is king information is the key to the
  kingdom.
• If you cant measure it, you cant manage it.
• The highest quality health care will be the
  lowest cost.
• There are not 10 best ways to do anything.

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The Q Word

• First Domain is Safety
• Then, Evidence-Based Medicine (as applicable)
• clinical quality
• And..
• functional health status
• patient satisfaction

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Evidence-Based Medicine
Variation in Care
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Employers Role

• Business Case
• Supply chain integration
• Leverage clout
• Measure

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Overview

• Inpatient data
• Outpatient data
• Patient Satisfaction
• Demonstration Projects
• Education
• Community Service

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Inpatient Quality Initiative 1991 MediQual -
Atlas

• Appropriateness
• Effectiveness
• Efficiency

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CENTRAL FLORIDA HEALTH CARE COALITION
32
28.3
Current National Average 22
26.3
22.9
23
19.8
20
19
18
17
17
17
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CEA w/o Cerebral Infarction(less than 2 days
pre-op)
6 Mos Transition 11 24 2.12 5,750 1

• Pre-op ang.
• ICU adm.
• LOS
• Costs
• Deaths

Pre-pathway 32 77 2.93 7,798 0
Post 4 9 1.68 5,387 1
Summary -28 -69 -1.25 days -2,411 2
Now 2 3 1.4 days -6,000
n 733
n 588
n 129
n 66
Savings 1,767,263
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FOCUS DRGs
Normal Delivery Open Heart/CABG C-Section
PTCA Hysterectomy Acute MI COPD Chest
Pain Pneumonia Appendectomy Pediatric Asthma
Small/Large Bowel Total Hip/Knee Lap Gall
Bladder Back/Neck Procedure Gastroenteritis
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CFHCC Utilization
EXAMPLE
Units/Case
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Provider Inpatient Performance
BEST
12,500
10,000
4
7,500
5,000
2,500
0
(2,500)
(5,000)
(7,500)
N
z
(10,000)
(12,500)
-2
-1.5
-1
-0.5
0
0.5
1
1.5
2
National
Peer
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Demonstration Projects

• determined by data
• benchmark against best practices
• currently 9 underway

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Demonstration Projects

• Arthritis
• H. Pylori
• Hypertension
• Cardiovascular Disease (statin use)
• Lower Back
• Peripheral Artery Disease
• Asthma
• Depression
• Hepatitis C

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Regional Hospital Connectivity
SWIFT M.D. System Wide Information at your
Finger Tips RIFT Pro
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Regional Hospital Connectivity

• Trifecta
• vast patient safety improvement
• cost reduction
• improve physicians quality of life

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Regional Hospital Connectivity

• Patient Safety
• on-time information
• history of comparisons
• calculators
• EBM

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Regional Hospital Connectivity

• Cost Reduction
• no duplication
• timely diagnosis
• fewer errors

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Regional Hospital Connectivity

• Physician Quality of Life
• connect from home
• no reliance on relay
• medical liability relief

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Regional Hospital Connectivity
Benefits

• No software access anywhere
• Data displays in real time
• No storage - access legacy systems
• Physician training (1 hour)
• HIPAA compliant

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Outpatient Quality Initiative
The Challenges...

• Multiple Sites
• Multiple Specialties
• No Communication
• Great Variation

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Adverse Effects in Outpatient Care

• Up to 18 of O/P suffer adverse effects
• Cost 77 billion annually
• Results in
• 8 million hospital admissions
• 17 million ER visits
• 77 million extra prescriptions
• 116 million doctor visits

Source Weingart, et al., BMJ 2000
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Outpatient
The Participants...
Over 250,000 covered lives
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Outpatient Quality Initiative
FIRST MEASURES TOP 10 CONDITIONS - PHASE I
Data review included most episodes, most costly
episodes and roll-up of all costs to determine
aggregate costs per condition. Opportunity to
educate also considered.

• Lower Respiratory Infection
• Sinusitis
• Hypertension
• Lipid/Cholesterol Disorder
• Abdominal Pain

• CHF
• Arthritis
• Diabetes
• Asthma
• Ischemic Heart Disease/Angina

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Outpatient Quality Initiative
FIRST SPECIALISTS PRACTICE EFFICIENCY - PHASE I

• Family Practice
• Internal Medicine
• Gastroenterology
• Cardiology
• OB/GYN

Analysis for all conditions - minimum of 20
cases Analysis for specific care for
specialty only - minimum of 10 cases
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Primary Care Physician ProfileFamily Practice
Average Charge Per Episode

• Episodes
• Hypertension
• Headache
• Abdominal Pain
• Acute Pharyngitis
• L. Resp. Infection

Provider 933 297 191 132 278
Specialty 410 216 291 77 122
Network 403 211 321 77 134
Number 86 50 92 93 84
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Services ProfileFamily Practice Lower
Respiratory Infection
Used 100 64.3 35.7 35.7 28.6 21.5

• Services
• Office Visit
• CBC
• Chemistry
• EKG
• Chest X-ray
• Pulm. Func.
• ALL

Provider 1.3 0.9 0.4 0.4 0.9 0.4 6.1
Specialty 0.8 0.3 0.2 0.1 0.2 0.1 2.5
Network 0.9 0.3 0.2 0.0 0.3 0.1 3.0
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Medication ProfileFamily Practice Acute
Pharyngitis

• Medications
• Amox/Ampicillin
• Pen V VK
• Cephalosporin
• Cough Cold
• Antihistamines

Provider 14.3 0 64.3 7.1 50
Specialty 14 6.5 25.2 27.1 8.4
Network 34.9 6.2 27 33.6 5.8
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Primary Care Physician ProfileHypertension
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Primary Care Physician ProfileHypertension
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Actual Performance Plan Comparisons
Detailed Results Getting Care
CONFIDENTIAL
Medical Office Staff Courteous and Helpful
1999
1997
1998
CAPP Care PPO(Base 175)
CAPP Care PPO(Base 471)
CAPP Care PPO(Base 239)
Prucare PPO(Base 480)
Prucare PPO(Base 486)
Prucare PPO(Base 472)
Healthchoice PPO(Base 146)
Healthchoice PPO(Base 134)
Healthchoice PPO(Base 244)
CIGNA PPO (Base 70)
CIGNA PPO (Base 188)
CIGNA PPO (Base 213)
BCBS PPO(Base 106)
BCBS PPO(Base 123)
BCBS PPO(Base 109)
UHC PPO(Base 0)
UHC PPO(Base 264)
UHC PPO(Base 273)
N/A
Prucare HMO(Base 371)
Prucare HMO(Base 470)
Prucare HMO(Base 377)
CIGNA HMO(Base 424)
CIGNA HMO(Base 408)
CIGNA HMO(Base 405)
AvMed HMO(Base 147)
AvMed HMO(Base 148)
AvMed HMO(Base 170)
BCBS POS(Base 0)
BCBS POS (Base 113)
N/A
N/A
BCBS POS(Base 0)
CAHPS 1999
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Actual Performance Plan Comparisons
Detailed Results The Health Plan
CONFIDENTIAL
Customer Service Efficiency and Helpfulness
1999
1997
1998
CAPP Care PPO(Base 77)
CAPP Care PPO(Base 290)
CAPP Care PPO(Base 115)
Prucare PPO(Base 249)
Prucare PPO(Base 257)
Prucare PPO(Base 267)
Healthchoice PPO(Base 52)
Healthchoice PPO(Base 46)
Healthchoice PPO(Base 89)
CIGNA PPO (Base 33)
CIGNA PPO (Base 98)
CIGNA PPO (Base 104)
BCBS PPO(Base 58)
BCBS PPO(Base 63)
BCBS PPO(Base 55)
UHC PPO(Base 114)
UHC PPO(Base 96)
UHC PPO(Base 0)
N/A
Prucare HMO(Base 176)
Prucare HMO(Base 241)
Prucare HMO(Base 204)
CIGNA HMO(Base 188)
CIGNA HMO(Base 229)
CIGNA HMO(Base 211)
AvMed HMO(Base 88)
AvMed HMO(Base 85)
AvMed HMO(Base 89)
BCBS POS(Base 0)
BCBS POS (Base 63)
BCBS POS(Base 0)
N/A
N/A
CAHPS 1999
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Actual Performance Plan Comparisons
Detailed Results Getting Care
CONFIDENTIAL
Getting the Care You Need
1999
1997
1998
CAPP Care PPO(Base 192)
CAPP Care PPO(Base 513)
CAPP Care PPO(Base 245)
Prucare PPO(Base 527)
Prucare PPO(Base 537)
Prucare PPO(Base 519)
Healthchoice PPO(Base 150)
Healthchoice PPO(Base 141)
Healthchoice PPO(Base 260)
CIGNA PPO (Base 76)
CIGNA PPO (Base 203)
CIGNA PPO (Base 227)
BCBS PPO(Base 112)
BCBS PPO(Base 135)
BCBS PPO(Base 117)
UHC PPO(Base 278)
UHC PPO(Base 278)
UHC PPO(Base 0)
N/A
Prucare HMO(Base 441)
Prucare HMO(Base 528)
Prucare HMO(Base 442)
CIGNA HMO(Base 471)
CIGNA HMO(Base 444)
CIGNA HMO(Base 447)
AvMed HMO(Base 177)
AvMed HMO(Base 172)
AvMed HMO(Base 186)
BCBS POS(Base 0)
BCBS POS (Base 135)
BCBS POS(Base 131)
N/A
N/A
CAHPS 1999
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CAPS (Consumer Assessment of Physicians Study)

• Core areas
• Access (5)
• Care (8)
• Wellness (5)
• Satisfaction (3)
• Impairment (7)
• Parallels from SF36 12
• Rx Compliance (3)

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CAPS (Consumer Assessment of Physicians Study)

• 2001 Demonstration Project
• 100 physicians
• 30 completes
• Post cards
• 6000 initial mailings (9/8/01)
• 3900 second mailing

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CAPS (Consumer Assessment of Physicians Study)

• Sampling Issues
• Patient age
• Claim payments not within 6 months
• Patient knowledge of physician
• Radiologists
• Pathologists
• Billing doc (same practice but)
• Avoid peak terrorism periods!

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CAPS (Consumer Assessment of Physicians Study)

• 2003
• 804 Primary Care physicians
• 60 completes
• Post cards
• Electronic surveys

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Demonstration Projects

• determined by data
• benchmark against best practices
• currently 9 underway

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Demonstration Projects

• Depression
• Objectives
• Eliminate / Reduce signs and symptoms
• Restore occupational and social functioning
• Reduce likelihood of relapse and recurrence

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Demonstration Projects
Phases of Depression Treatment
Source Adapted from Kupfer DJ. J Clin
Psychiatry, 1991
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Demonstration Projects
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Demonstration Projects

• Depression

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Demonstration Projects

• Depression

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Demonstration Projects

• Depression

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Demonstration Projects

• Depression

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Demonstration Projects

• H. Pylori Project
• Phase II - Florida Power Light
• paper screen
• testing
• follow-up for compliance
• FPL integrate in their programs
• expanded in 2003

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Demonstration Projects

• Peripheral Artery Disease
• Orange County Public Schools and Polk County
  Schools
• screenings
• determine prevalence
• care patterns

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Demonstration Projects

• Hepatitis C
• Brevard County Government
• public safety employees
• education
• screening

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Demonstration Projects

• Open Airways for Schools
• American Lung Association of Central Florida
• 440 children in Central Florida
• Childrens attendance ? 63
• ER visits ? 64
• Physician visits ? 70
• Parents at work ? 64

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Demonstration Projects

• Cardiovascular Disease
• Lipid testing
• Use of statins
• Inpatient vs. outpatient

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Demonstration Projects

• Arthritis
• Top five increases in diagnosis
• COX 2 for treatment
• Frequency and appropriateness

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Demonstration Projects

• Low Back Pain
• Outpatient database
• 7th in Episodes of Care
• 8th in overall costs
• CAHPS
• Ranked 3rd in reported episodes
• 14 of respondents treated
• Undoubtedly higher incidence in workers
  compensation arena
• Dr. Robert Westergan, Jewett Orthopaedic Clinic

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Demonstration Projects

• Hypertension
• and
• Treat to goal
• Hypertension hyperlipidemia testing
• Self-test blood pressure
• Unique identifier to enter portal
• Dr. Scott Greenwood

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Demonstration Projects

• Inappropriate drug use
• Physician practice patterns patient
  satisfaction
• Sleep Disorders
• Prostate
• Womens Health
• Obesity in Children

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Purchasing

• Instrument of change
• Partnership
• Align incentives

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Purchasing

• Pay for Performance
• Evidence-based medicine (EBM)
• Identify and communicate best practices

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Employers Role

• Pay for Performance
• Align incentives
• Collaborate
• Velvet hammer

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Purchasing

• Three tier physicians
• Data driven - focus on EBM
• Planned evolution

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Purchasing

• Align Incentives
• financial
• non-financial

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Improving Quality
Specific Quality Measures, Data Sources, IT

• Information Technology
• MEDecisions PRS profiler to create physician
• practice patterns
• Millimans MedInsight Information System for
• actuarial work
• data reliability
• clinical acceptability
• impact on cost
• impact on quality
• practice variability

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Purchasing

• Financial Rewards Rankings
• 65 clinical outcomes
• 20 patient satisfaction
• 15 service appropriate utilization

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Improving Quality
Specific Quality Measures, Data Sources, IT

• Specific Quality Measures
• Work in process
• 60 initial measures and indicators
• evaluated (CPT codes, ICD-9 codes)
• Additional indicators from NCQA, JCAHO,
• NQF, Leapfrog, Disclosure Project other
• research

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Purchasing

• Platinum - Initially
• Highest reimbursement rate
• Higher for chronic illnesses
• No pre-certs, pre-authorizations, etc.
• Low co-pay

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Purchasing

• Platinum - One year
• Digital prescribing
• One week mini-residency
• Platinum - Two years
• Common computer systems (EMR)
• Best practices communication
• Platinum - Five years
• On-line profiling
• Electronic payment

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Purchasing

• Gold
• Lower reimbursement rate
• Some managed care controls
• Higher co-pay
• Gold - One year
• Updated profile
• Digital prescribing
• Mini-residency

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Purchasing

• Silver
• Lowest reimbursement
• Allow balanced billing
• Highest co-pay
• training available

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Purchasing

• Non-financial incentives
• Annual performance report received
• Streamlined care processes
• Mini-residency
• Licensing CME requirement met
• Patients have reduced co-pay limits
• Less uncollectable money
• Electronic payment
• Lower malpractice premiums

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Purchasing

• Partnerships
• Combining the best of medicine with the best of
  business.
• Task forces

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Purchasing
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Purchasing

• Evaluation
• Office of Health Policy and Clinical Outcomes
  Thomas Jefferson University
• David Nash, MD, MBA
• Neil Goldfarb, Director of Research
• Pre-post interventions

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Purchasing

• Platinum Consumer
• Improve consumer compliance
• Improve consumer education

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Purchasing

• Consumer communication characters
• Whoknew?
• Ben E. Fit
• Bea Fit

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Financial Impact
Considers...

• Current mix of health plans
• Number of enrollees in each plan
• Number of physicians
• Current reimbursement rates

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Financial Impact
Upon ONE General Practitioner

• 35 patients per day (7,000 per year)
• 200 days per year
• 80 average reimbursement per visit
• 560,000 revenue per year

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Financial Impact
Upon ONE General Practitioner
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Savings

• Hypertension
• 933 - 403 530 x 68 36,040
• Acute Pharyngitis
• 132 - 77 55 x 93 5,115
• Lower Respiratory
• 278 - 134 144 x 84 12,096
• Total Savings 53,251

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Purchasing

• THE Q
• Quality First, Always!

Total Healthcare with EBM for Quality
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(No Transcript)
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Dont explain why it cant be done. Discover
how it can be done. Mo
Tao (404-319 B.C.)